mHealth for Development: The Opportunity of Mobile Technology

Transcription

mHealth for Development
The Opportunity of Mobile Technology for Healthcare in the Developing World
1
Author
Vital Wave Consulting
About The United Nations Foundation and Vodafone Foundation
Technology Partnership
The United Nations Foundation and Vodafone Foundation Technology Partnership is a leading publicprivate alliance using strategic technology programs to strengthen the UN’s humanitarian efforts
worldwide. The Partnership has three core commitments: (1) to support the use of rapid response mobile
telecommunications to aid disaster relief; (2) to develop health data systems that improve access to health
data thereby helping to combat disease; and (3) to promote research and innovative initiatives using
technology as an agent and tool for international development. Further information can be found at:
www.unfoundation.org/vodafone.
Contact
United Nations Foundation
1800 Massachusetts Ave., NW
Suite 400
Washington, D.C. 20036
USA
The Vodafone Foundation
Vodafone House
The Connection
Newbury, Berkshire, RG14 2FN
UK
Registered Charity No: 1089625
Recommended Citation
Vital Wave Consulting. mHealth for Development: The Opportunity of Mobile Technology for Healthcare
in the Developing World. Washington, D.C. and Berkshire, UK: UN Foundation-Vodafone Foundation
Partnership, 2009.
Cover Photo Credits
UN Mark Garten and UN Foundation.
Foreword
The United Nations Foundation and The Vodafone Foundation are working
together to harness the power of mobile technology in support of United
Nations programs across the globe. Since 2005 our £15 million Technology
Partnership has funded the use of wireless communications to advance global
health and disaster relief work, and to further public discourse about how
wireless technology can address some of the world’s toughest challenges.
This fourth publication, “mHealth for Development: The Opportunity of
Mobile Technology for Healthcare in the Developing World,” in our Access
to Communications series evidences, through its research and selection of
case studies, the potential of mHealth—the use of mobile communications
(mobile phones and PDAs) for health services and information. This field has
the potential to transform the approach to a variety of healthcare challenges
in the developing world by accelerating the collection and storage of patient
data, training rural professionals with health updates and guidance, and
personalizing to new levels the process of patients receiving and engaging in
available medical treatment.
As the case studies in the report demonstrate, governments, companies, and
non-profit groups are already developing mHealth applications to improve
healthcare and consequently save lives. These new mobile applications,
bypassing the fixed-line solutions, are creating new pathways for sharing
health-related information, even in the most remote and resource-poor environments.
We invite you to review the potential of this area of activity and join the discussion of mHealth for
development. We would welcome your comments and ideas at www.unfoundation.org/mHealth-report.
Vittorio Colao
Colao, CEO
Vodafone
Foreword
Ted Turner
Turner, Chairm
Chairman
United Nations Foundation
1
1
Acknowledgements
The United Nations Foundation and The Vodafone Foundation are thankful to the numerous
individuals who have shared their ideas and experiences to inform this report and to contribute to
the advancement of the mHealth field. In particular, we would like to thank Ken Banks, Founder of
kiwanja.net; Greg Elphinston, Director Community Involvement at Nokia; Dr. Adesina Iluyemi of the
University of Portsmouth; Vuyani Jarana, Regional Operations Director at Vodacom Africa; Eduardo
Jezierski, Vice President of Engineering at InSTEDD; Jørn Klungsøyr, Researcher / Developer,
Centre for International Health at the University of Bergen; Dr. Jennifer Leaning, Professor of
International Health at Harvard School of Public Health and Associate Professor of Medicine at the
Harvard Medical School; Dr. Balcha Masresha, World Health Organization; Dr. Patricia N. Mechael,
mHealth and Telemedicine Advisor to the Millennium Villages Project at the Earth Institute at
Columbia University; Lauri Medeiros, Director, Corporate and Foundation Relations at the University
of California, San Francisco; Jesse Moore of the GSM Association; Dr. Joel Selanikio, Co-founder
and Director of DataDyne; John Stephenson from Dalberg Global Development Advisors; Dr. Boris
Nikolic, Senior Program Officer, Global Health Discovery at the Bill & Melinda Gates Foundation;
and Dr. Pammla Petrucka, Associate Professor, University of Saskatchewan, College of Nursing.
We are also appreciative of the support of the organizations that shared their experiences with
us in the case studies. Thank you to Hajo van Beijma, Co-founder of Text to Change; Robin Miller
and Sheetal Gordhan of the Praekelt Foundation (Project Masiluleke); Andre Erthal, Head of the
Community Group at Nokia Mobile Solutions and Services (Nokia Data Gathering); and Neal Lesh,
Chief Technology Officer at D-Tree International (OpenRosa).
This report would not have been as compelling without the rich pictures contributed by DataDyne,
ENACQKT: Enhancing Nurses Access for Care Quality and Knowledge through Technology, the
Praekelt Foundation (Project Masiluleke), RAMP: Recycled AIDS Medication Program, Text to
Change, UNICEF, and the United Nations.
Lastly, we would like to thank the team that worked on creating and producing this report. This
includes Vital Wave Consulting, copyeditor Lelani Arris, and Hal Kowenski and Andre Temoney at
Linemark Printing. ■
2
Acknowledgements
Contents
Foreword __________________________________________________________________________ 1
Acknowledgements _______________________________________________________________ 2
Contents __________________________________________________________________________ 3
Introduction _______________________________________________________________________ 4
Potential of Mobile Phones to Improve Health in the Developing World ___________ 6
The Promise of Mobile Technologies for Health
7
Defining mHealth Within the Context of eHealth __________________________________ 8
Meeting Health Needs Through a Broad Array of Applications ____________________ 9
Education and Awareness
10
Remote Data Collection
11
Remote Monitoring
12
Communication and Training for Healthcare Workers
13
Disease and Epidemic Outbreak Tracking
13
Diagnostics and Treatment Support
14
Examining the Impact of mHealth Projects _______________________________________ 15
Assessing mHealth and Future Health Needs in Developing Countries ___________ 18
Evolution of Mobile Technologies
20
Identifying the Building Blocks for Sustainable and Scalable mHealth Programs 21
Key Building Blocks for Success
21
Project Masiluleke
22
Multiple Health Issues Addressed by SMS Campaigns
24
Text to Change (TTC)
25
Data Gathering
28
Open Source Movement: A Building Block for mHealth Success
30
Understanding the Incentives for Multiple Players: mHealth Value Chain ________ 31
Value Chain Models for mHealth: One-way Data Applications
31
Value Chain Models for mHealth: Two-Way Data Applications
33
A Call for Action _________________________________________________________________ 34
Operators
34
NGOs
35
Policymakers
36
Funders
36
Conclusion: Looking Forward ____________________________________________________ 37
Compendium of mHealth Projects________________________________________________ 39
41
43
Remote Monitoring
50
55
58
Diagnostic and Treatment Support
62
Contents
3
Introduction
Credit: DataDyne
Mounting interest in the field of mHealth—the provision of health-related services via mobile communications—can be traced to the evolution of several interrelated trends. In many parts of the world, epidemics
and a shortage of healthcare workers continue to present grave challenges for governments and health
providers. Yet in these same places, the explosive growth of mobile communications over the past decade
offers a new hope for the promotion of quality healthcare. Among those who had previously been left behind
by the ‘digital divide,’ billions now have access to reliable technology.
There is a growing body of evidence that demonstrates the potential of mobile communications to radically
improve healthcare services—even in some of the most remote and resource-poor environments. This report
examines issues at the heart of the rapidly evolving intersection of mobile phones and healthcare. It helps the
reader to understand mHealth’s scope and implementation across developing regions, the health needs to
which mHealth can be applied, and the mHealth applications that promise the greatest impact on heath care
initiatives. It also examines building blocks required to make mHealth more widely available through sustainable implementations. Finally, it calls for concerted action to help realize mHealth’s full potential.
The report is organized into the following sections:
1 Identifying the potential of mobile phones to improve health in the developing world
2 Defining mHealth within the context of eHealth
3 Meeting health needs through a broad array of mHealth applications
4 Examining the impacts of mHealth projects
5 Assessing mHealth and future health needs in developing countries
6 Identifying the building blocks for sustainable and scalable mHealth programs
7 Understanding the incentives for multiple players: mHealth value chains
8 A call for action
9 Looking forward
10 Compendium of mHealth projects
4
Introduction
Though the mHealth field is still in its early stages, it has already begun to transform health delivery. Projects throughout the developing world are demonstrating concrete benefits, including:
■
Increased access to healthcare and health-related information, particularly for hard-to-reach populations
■
Improved ability to diagnose and track diseases
■
Timelier, more actionable public health information
■
Expanded access to ongoing medical education and training for health workers
Due in large part to the successes of pioneering mHealth programs, activity in the field is rapidly gaining
momentum. In 2008 alone, over a dozen new mHealth applications have been implemented or are in the
trial stage. These include:
■
InSTEDD, a US-based non-governmental organization (NGO) that provides technology solutions for
humanitarian and disease support, opened a development center in Cambodia where mHealth-based
disease and surveillance solutions are being designed for the Southeast Asian region.
■
The Canadian development agency, IRDC, expanded support for a project providing nurses in the Caribbean with portable digital assistants (PDAs) to empower improved diagnosis and decision making.
■
The United Nations Foundation and Vodafone Foundation Technology Partnership, together with the
World Health Organization (WHO), a specialized agency of the United Nations (UN), announced plans
to expand their mobile data-gathering program to more than 20 countries in sub-Saharan Africa.
This report profiles more than 50 mHealth projects taking place in the developing world. The long-term goal
is that such programs will make healthcare more effective, and have a demonstrable and significant positive impact on clinical outcomes such as reduced infant mortality, longer life spans, and decreased contraction of disease.
Experts across the field, and interviewed as part of this report, assert that there is an unprecedented
opportunity at hand to fulfill mHealth’s promise. To accelerate this momentum and fully unleash the
potential of mHealth applications, dynamic multi-sector collaboration between groups as
diverse as governments, multilateral organizations, and the private sector is needed. Joint
action should be directed toward the creation of a global mHealth infrastructure that lays out common
standards and guidelines, and serves as a repository for shared resources and best practices. This is the
best approach for scaling mHealth solutions and maximizing the field’s capacity to serve a vital development imperative. ■
“Right now, we are at an inflection point in terms of acceptance.
Whether it turns out to be the peak of inflated expectation or the
trough of disillusionment will depend on whether governments
make the link between telecommunication policy and health, and
the extent to which donors encourage transparency in sourcing
and the participation of local entrepreneurs. Ultimately, the takeup of mobile communications in the health sector isn’t really
about technology at all.”
—Greg Elphinston,
Director Community Involvement, Nokia
Introduction
5
Potential
Credit: DataDyne
Potential of Mobile Phones to Improve Health in
the Developing World
As the first decade of the 21st century draws to a close, leaders in many developing countries can point with
pride to tremendous strides in their efforts to improve the lives of their citizens. In many parts of the world,
citizens in emerging economies have begun to taste the fruits of higher incomes and greater access to tools
that promise to increase their quality of life and that of their children. Yet formidable obstacles remain. Health
challenges present arguably the most significant barrier to sustainable global development. Disease and the
lack of adequate preventative care take a significant toll on both developing populations, measurable in disability-adjusted life years (DALYs), and economies. Despite the broad economic advances of this decade, the
2008 UN report on progress toward meeting the Millennium Development Goals (MDGs) indicates continuing
dire conditions in crucial public health areas. For example:1
■
A child born in a developing country is over 33 times more likely to die within the first five years of life
than a child born in an industrialized country, even though the leading causes of deaths (pneumonia,
diarrhea, malaria, and measles) are preventable through basic services and vaccinations.
■
Every minute, at least one woman dies from complications related to pregnancy or childbirth. And for
every woman who dies in childbirth, approximately 20 more suffer injury, infection, or disease—nearly 10
million each year.
■
An estimated 2.5 million people were newly infected with HIV in 2007.
■
Communicable, and entirely avoidable, diseases such as tuberculosis (TB) and malaria continue to claim
lives due to preventable factors such as lack of access to proper drugs and medical treatment. By current estimates, meeting the target MDG of halving the TB prevalence rate by 2015 is unlikely.
1
United Nations, The Millennium Development Goals Report 2008 (New York: United Nations, 2008).
6
Potential of Mobile Phones to Improve Health in the Developing World
Health-Related Millennium Development Goals
MDG 4.
Reduce child mortality: Reduce by two-thirds, between 1990 and 2015,
the under-five mortality rate.
MDG 5.
Improve maternal health: Reduce by three-quarters, between 1990
and 2015, the maternal mortality ratio.
MDG 6.
Combat HIV/AIDS, malaria, and other diseases: Have halted by 2015
and begun to reverse the spread of HIV/AIDS; have halted by 2015 and
begun to reverse the incidence of malaria and other major diseases.
The ability of developing countries to overcome these serious health challenges is hindered by several core
obstacles, among them a global shortage of healthcare workers. According to the WHO, among 57 countries, mostly in the developing world, there is a critical shortfall in healthcare workers, representing a total
deficit of 2.4 million healthcare workers worldwide.2 This human resources constraint intensifies the already
increasing pressure on developing-world health systems. Not only must they cope with the burden of containing the spread of communicable diseases associated with extreme poverty, they must also contend with
the growing incidence of chronic diseases, such as diabetes and heart disease, an effect of new-found (relative) affluence. Governments, businesses, NGOs, foundations, and multilateral organizations all recognize the
importance of leveraging new tools and solutions to address these distinct but interrelated health challenges.
The Promise of Mobile Technologies for Health
Mobile communication offers an effective means of bringing healthcare services to developing-country
citizens. With low-cost handsets and the penetration of mobile phone networks globally, tens of millions of
citizens that never had regular access to a fixed-line telephone or computer now use mobile devices as daily
tools for communication and data transfer. A full 64% of all mobile phone users can now be found in the developing world.3 Furthermore, estimates show that by 2012, half of all individuals in remote areas of the world
will have mobile phones. This growing ubiquity of mobile phones is a central element in the promise of mobile
technologies for health.
Figure 1 illustrates that developing world citizens have plentiful access to mobile phones, even while other
technologies and health infrastructure are scarce. This explosion of mobile phone usage has the potential to
improve health service delivery on a massive scale. For example, mobile technology can support increasingly
inclusive health systems by enabling health workers to provide real-time health information and diagnoses in
rural and marginalized areas where health services are often scarce or absent altogether. ■
5,300
5,000
4,000
Mobile phones reach
further into developing
countries than other
technology and health
infrastructures.
3,000
2,293
2,000
1,000
305
0
11
Hospital Beds
Computers
Mobile Phones
Population
Figure 1. Technology and health-related statistics for developing countries (millions).4
2
World Health Organization, The World Health Report 2006 - Working Together for Health (Geneva: WHO, 2006).
3
United Nations Department of Economic and Social Affairs, Division for Public Administration and Development Management, Compendium of ICT Applications on Electronic Government - Volume 1. Mobile Applications on
Health and Learning (New York: United Nations, 2007).
4
Vital Wave Consulting, Business Monitor International (BMI), International Telecommunications Union, World Bank’s World Development Indicators, and the United Nations.
Potential of Mobile Phones to Improve Health in the Developing World
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Definition
“mHealth involves using
wireless technologies
such as Bluetooth, GSM/
GPRS/3G, WiFi, WiMAX,
and so on to transmit
and enable various
eHealth data contents and
services. Usually these are
accessed by the health
worker through devices
such as mobile phones,
Credit: Praekelt Foundation
smart phones, PDAs,
laptops and tablet PCs.”
Defining mHealth Within the
Context of eHealth
—Dr. Adesina Iluyemi,
PhD Candidate,
University of Portsmouth, UK
In recent years, mHealth has emerged as an important subsegment of the field of electronic health (eHealth). While there
is no widely agreed-to definition for these fields, the public
health community has coalesced around these working definitions:
“With eHealth
■
■
eHealth: Using information and communication technology (ICT)—such as computers, mobile phones, and satellite communications—for health services and information.
mHealth: Using mobile communications—such as PDAs
and mobile phones—for health services and information.
mHealth and eHealth are inextricably linked—both are used to
improve health outcomes and their technologies work in conjunction. For example, many eHealth initiatives involve digitizing patient records and creating an electronic ‘backbone’ that
ideally will standardize access to patient data within a national
system. mHealth programs can serve as the access point for
entering patient data into national health information systems,
and as remote information tools that provide information to
healthcare clinics, home providers, and health workers in the
field. While there are many stand-alone mHealth programs,
it is important to note the opportunity mHealth presents for
strengthening broader eHealth initiatives. ■
8
and mHealth, an
ecosystem approach is
recommended. Many of
the basic applications and
devices exist and are in
use, but now we need to
make them talk to each
other in a way that yields
strategic benefits.”
—Dr. Patricia Mechael,
mHealth and Telemedicine Advisor to
the Millennium Villages Project at the
Earth Institute at Columbia University
Defining mHealth Within the Context of eHealth
Applications
Credit: DataDyne
Meeting Health Needs
Through a Broad Array of
Applications
Africa (excluding
South Africa and
Uganda), 9
South Africa, 6
A growing number of developing countries are using mobile
technology to address health needs. The mHealth field is
remarkably dynamic, and the range of applications being
designed is constantly expanding. The key applications for
mHealth in developing countries are:
■
Education and awareness
■
Remote data collection
■
Remote monitoring
■
Communication and training for healthcare workers
■
Disease and epidemic outbreak tracking
■
Diagnostic and treatment support
This report details 51 mHealth programs, either currently
operating or slated for implementation in the near future,
that are taking place in 26 different developing countries.
mHealth programs are more prevalent in some countries
than others for reasons that have not yet been assessed
by the academic literature. In particular, India, South Africa, Uganda, Peru, and Rwanda stand out for their level
of mHealth activity. As the case studies examined in this
report reveal, mHealth programs are gaining strong support
across regions, as well as sectors as diverse as governments, technology providers and academia. Figure 2 shows
the geographic and application area breakdown of these
mHealth projects.
Meeting Health
Needs
Through
a Broad
Array of Applications
Defining
mHealth
Within
the Context
of eHealth
Latin America, 10
Uganda, 6
India, 11
Worldwide, 1
Eastern Europe, 1
Asia (excluding
India), 7
Diagnostic and
Treatment Support, 9
Education and
Awareness, 6
Disease and
Epidemic Outbreak
Tracking, 7
Communication and
Training for Health
Care Workers, 5
Remote Data
Collection, 14
Remote monitoring,
10
Figure 2. Distribution of mHealth programs by location and application area.
9
Worldwide:
FrontlineSMS
Education & Awareness
Remote monitoring
Communication & Training for Health Care Workers
Disease & Epidemic Outbreak Tracking
Diagnostic & Treatment Support
Figure 3. Distribution of mHealth programs by location and application area.
Figure 3 provides another view of the distribution of mHealth programs both geographically and
by application area.
The following section describes the major mHealth applications in developing countries and provides examples of projects where the application has been put into action.
Popularized by teenagers in western countries and Japan who wanted a low-cost means of
communicating with friends, short message service (SMS) messages now offer a cost-effective,
efficient, and scalable method of providing outreach services for a wide array of health issues.
In education and awareness applications, SMS messages are sent directly to users’ phones to
offer information about testing and treatment methods, availability of health services, and disease
management. Formal studies and anecdotal evidence demonstrate that SMS
alerts have a measurable impact on and a greater ability to influence behavior
than radio and television campaigns. SMS alerts provide the further advantage of being
relatively unobtrusive, offering recipients confidentiality in environments where disease (especially
HIV/AIDS) is often taboo. In the developing world, SMS alerts have proven particularly effective
in targeting hard-to-reach populations and rural areas, where the absence of clinics, lack of
healthcare workers, and limited access to health-related information all too often prevent people
from making informed decisions about their health.
SMS message campaigns can be set up either as one-way alerts or interactive tools used for
health-related education and communication. For example, a citizen may sign up to take a survey,
delivered via SMS message, quizzing them on their knowledge about HIV/AIDS and the location
of the nearest testing center. Depending upon their responses, information regarding where and
how to receive a free test will be transmitted. This interactive model has been deployed in several
countries (e.g., India, South Africa, and Uganda) to promote AIDS education and testing and provide information about other communicable diseases (such as TB), as well as to promote maternal health and educate youth about reproductive health.
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Meeting Health Needs Through a Broad Array of Applications
Project Masiluleke and Text to Change use SMS message campaigns to
provide HIV/AIDS education in South Africa and Uganda, respectively.
Project Masiluleke takes advantage of the 120 spare characters on free
‘please call me’ SMS messages to provide HIV/AIDS education and
awareness, while Text to Change employs an SMS-based quiz to test
users’ HIV/AIDS knowledge and encourage testing and counseling.
While other communication mediums, such as radio, television, voice-based information hotlines,
and even interactive websites can be employed in the service of education about public health
issues, SMS stands out as having several advantages over each of these: cost-effectiveness,
scalability, convenience, broad reach, and widespread popularity in the developing world.
By promoting health-conscious behavior, the mHealth education and awareness programs currently in place have already had positive impacts. The ubiquity and low cost of SMS messages
hold the potential to shift the paradigm for health education by communicating with people in an
accessible, engaging manner that both respects their privacy and gives them the tools to make
informed choices.
Data collection is another crucial component of public health programs. Policymakers and health
providers at the national, district, and community level need accurate data in order to gauge the
effectiveness of existing policies and programs and to shape new ones. In the developing world,
collecting field information is particularly important since many segments of the population are
rarely able to visit a hospital, even in the case of severe illness. Gathering data where patients live
is vital, and information should ideally be updated and accessible on a real-time basis. The data
collection process is more efficient and reliable if conducted via smartphones, PDAs, or mobile
phones rather than paper-based surveys that must be submitted in person and manually entered
into the central health database.
Data collection programs have been deployed in multiple developing world countries, mainly
as pilot projects. The most successful programs are scaling up and beginning to be deployed
in multiple countries or regions. These initiatives are closing the information gap
that currently exists for patient data in the developing world, enabling
public officials to gauge the effectiveness of healthcare programs, allocate
resources more efficiently, and adjust programs and policies accordingly.
Hundreds of health workers have used PDAs provided by the Ugandan
Health Information Network to collect health data in the field. Not only
has this solution resulted in significant cost savings—25% in the first six
months—but health workers report increased job satisfaction due to
the greater efficiency and flexibility provided by the technology.
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Credit: DataDyne
Remote Monitoring
One of the areas most uniquely suited to grow in tandem with mobile technology is the remote monitoring of patients. Remote monitoring opens new possibilities for treating patients in an outpatient setting, a crucial capability
in developing countries where access to hospital beds and clinics is limited. This group of applications consists
of one- or two-way communications to monitor health conditions, maintain caregiver appointments, or ensure
medication regimen adherence. Some applications may also include inpatient and out-patient sensors for monitoring multiple conditions.
Evidence shows that strict adherence to a medication regime is essential for effective treatment of a variety
of health conditions, from AIDS to diabetes. In addition, monitoring patients at home for chronic
conditions dramatically improves survival rates. Remote monitoring applications are being
implemented on a relatively limited basis in developing countries, but they are gaining traction in the developed
world, particularly for chronic diseases. As the benefits of these applications are documented in the developed
world and funding models evolve in developing countries, remote monitoring is expected to become widespread
and significantly improve health outcomes for a wide range of communicable and chronic diseases.
Remote Monitoring
TB patients in Thailand were given mobile phones so that healthcare
workers (themselves former TB patients) could call these patients on
a daily basis to remind them to take their medication. Medicine compliance rates reached 90% due to the introduction of this remote monitoring application.
12
Communication and Training for Healthcare
Workers
In the Primary Healthcare Nursing Promotion Program, the National
School for Nurses in Coban, Guatemala used an innovative combination of mobile phones, landline phones, and tele-writers to train nurses
in this rainforest community.
An acute shortage of healthcare workers is a major challenge facing developing country health sectors.
Training new cadres of health professionals and empowering current workers in order to increase job
satisfaction and reduce attrition are essential to meeting human capital needs. Connecting health
workers with sources of information via mobile technology is a strong basis for
empowerment, as it provides the support they need to perform their functions
effectively and self-sufficiently.5
There is also a pressing need to improve communication among different health units to facilitate more efficient patient care. Due to the dearth of landline phones and Internet-enabled computers, it is not uncommon, for example, for a patient to be sent to the regional hospital by the local clinic, only to find that there is
no bed available. Mobile phones can help bridge these communications gaps that in the health context can
often mean the difference between lives lost and lives saved.
Outbreaks of communicable diseases often begin in pockets, and, when left undetected, can develop
into epidemics. Recent instances of such devastating outbreaks abound, from cholera and TB to dengue
fever and Severe Acute Respiratory Syndrome (SARS). Deployment of mobile devices, with their
ability to quickly capture and transmit data on disease incidence, can be decisive in the
prevention and containment of outbreaks.
Disease and epidemic outbreak tracking mHealth applications are being used in Peru, Rwanda, and India as
an early warning system, allowing public health officials to monitor the spread of infectious diseases. Prior to
the adoption of mobile networks, public health officials relied upon written, satellite, and radio communication for such emergency tracking. The migration of this function to mobile systems is simultaneously improving data quality and lowering costs.
Incidents of Japanese Encephalitis were tracked real-time in Andhra
Pradesh, India, via a combination of mobile phones and web-based
technologies. The government used the information to better prioritize
vaccinations based on evidence of clusters of outbreaks.
5
Iluyemi, A. and J.S. Briggs. Access and Connectivity for Community Based Health Workers in Developing Countries: Employing Wireless Technologies, Med-e-Tel 2008 Conference, Luxembourg.
13
Diagnostics and Treatment Support
Diagnostics and treatment support are vitally important in healthcare—misdiagnosis or the inability to diagnose
a condition could have serious, even fatal, ramifications. mHealth applications in this area are designed to
provide diagnosis and treatment advice to remote healthcare workers through wireless access to medical
information databases or medical staff. With mHealth-enabled diagnostics and treatment
support, patients are able to receive treatment in their villages and homes, averting the
need for expensive hospital visits, which are beyond reach for many.
Diagnostic and treatment applications use the phone as a point-of-care device. Health workers’ phones are
typically equipped with specialized tools, such as built-in software that leads the worker through a step-bystep diagnostic process. Once data are entered into the system (e.g., symptoms and an image of a patient’s
injury captured on the mobile phone), remote medical professionals can diagnose the illness and prescribe
treatment. By eliminating the need for patient travel, these applications have the potential to dramatically increase access to care. ■
Researchers from the University of Melbourne are creating diagnostic
and analytical tools specifically for mobile phones for health workers in
Mozambique. These tools include a built-in calculator for determining
drug dosage and reference materials stored in the phone’s memory.
Credit: UN Tim Mc Kulka
14
Impact
Uganda
Text to Change’s SMS-based
HIV/AIDS awareness quiz led to
an increase of nearly 40% in the
number of people coming in for
free HIV/AIDS testing.
Peru
Cell-Preven. Health workers
use mobile phones to send
SMS messages with real-time
data on symptoms experienced
by clinical trial participants.
Enables immediate response
to adverse symptoms.
Philippines
Phoned Pill Reminders for TB
Treatment. TB patients were
given mobile phones and called
daily with reminder to take their
TB medication—90% did.
South Africa
Project Masiluleke’s SMS
message campaign promoting
HIV/AIDS awareness resulted in
nearly a tripling of call volume to
a local HIV/AIDS helpline.
Figure 4. Impact of mHealth applications across the developing world.
Examining the Impact of mHealth Projects
Formal studies and preliminary project assessments—in both the developed and developing world—demonstrate that mobile technology improves the efficiency of healthcare delivery, and ultimately makes healthcare
more effective. The long-term goal, and expectation, is that mHealth programs will have a demonstrable and
significant positive impact on clinical outcomes such as reduced infant mortality, longer life spans, and decreased contraction of disease. Figure 4 illustrates some early results from other mHealth programs across
the developing world.
Much of the excitement over the potential of mHealth centers on the developing world, where mHealth
programs put in place since the early part of the decade are now yielding actionable data that indicates that
some of the hoped-for benefits are materializing. These studies are complemented by those conducted in
the developed world—where mobile phones achieved a high level of penetration more than a decade ago—
that have begun to establish a significant body of evidence pointing to the health outcomes and efficiency
gains that can result from the thoughtful design and implementation of mobile-based programs and applications. A brief review of sample mHealth programs around the world demonstrates the palpable benefits of
using mobile phones in healthcare and prevention.
Improved Patient Health
Published clinical studies of mHealth programs point to an increasingly strong case for expanded mHealth
implementation. Patient health has been improved in three ways:
■
6
Improved compliance with treatment regimes: A 2007 Thai study showed that TB patients
who received daily text message medication reminders jumped to over 90% adherence. A device called
SIMpill that uses mobile technology to monitor and direct medication adherence6 also shows promise.
Phoned pill reminders make inroads against TB. The Nation (Bangkok), January 28, 2007.
Examining the Impact of mHealth Projects
15
A 2007 pilot in South Africa showed that with SIMpill, 90% of patients complied with their medication regime, compared with the typical 22 to 60% compliance rate without the system. The
solution is now available worldwide. In the United States, a study found improved drug adherence
rates among HIV-positive patients who received SMS
reminders to take daily medication compared to patients who did not. The majority of studies conducted
in Spain, Australia, Finland, and Korea on the benefits
of using mobile technology in areas such as vaccination follow-up and asthma or diabetes self-care conclude that mobile technology demonstrably improves
patient outcomes.
■
Improved public awareness outcomes: In
South Africa, Project Masiluleke, which promotes an
AIDS hotline through SMS messages, resulted in a
350% increase in phone calls to the hotline.
■
Improved disease management: A recent US
study on the use of wireless-enabled PDAs by Type 2
diabetes patients found greater improvements in blood
sugar indicators among regular users than among less
frequent users.7
“A 2007 pilot in South
Africa showed that
with SIMpill, 90% of
patients complied
with their medication
regime, compared with
the typical 22 to 60%
compliance rate without
the system.”
Improved Health Systems Outcomes
Efficiency gains enable improved quality of care. With efficiency gains, more resources can be freed up and distributed to a broader population, and service
programs can be strengthened. Examples of documented efficiency gains include:
■
In Uganda, an AED SATELLIFE program that uses wireless-enabled PDAs for disease surveillance,
collection, and reporting produced a 24% cost saving over the traditional paper approach. Eightyseven percent of healthcare workers involved in the program said it allowed them to make faster
and more accurate diagnoses.8
■
A Chinese study conducted by Zhejiang University researchers found that sending text messages
as appointment reminders improved attendance at a health promotion center as effectively as
phone reminders, while costing over one-third less.9
■
In the United Kingdom, researchers at the Imperial College, London, examined the health outcomes and efficiency gains that mobile device usage might bring to their national system. They
found that the annual direct cost of missed hospital appointments in England each year amounts
to £575 million. These costs are in addition to higher expenditures incurred by the health system
for patients whose health or treatment are negatively affected by missed appointments and who
then require additional medical attention.10
“When talking about efficiency versus health
impact, it shouldn’t be about either/or.
Improving efficiencies can ensure that more
people receive life-saving interventions.”
—John Stephenson,
Dalberg Global Development Advisors
7
Forjuoh, Samuel N., Michael D. Reis, Glen R. Couchman, and Marcia G. Ory. Improving Diabetes Self-Care with a PDA in Ambulatory Care. Telemedicine and e-Health. 14(3), April 2008. See http://www.liebertonline.com/toc/
tmj/14/3 for the article and author listing.
Gebru, Berhane. Disease Surveillance with Mobile Phones in Uganda. Retrieved 16 November 2008 from http://mobileactive.org/berhane-gebru-disease-surveillance-mobile-phones-uganda.
9
Chen, Zhou-wen, Li-zheng Fang, Li-ying Chen, and Hong-lei Dai. Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: A randomized controlled trial. Journal of
Zhejiang University Science. 9(1), January 2008.
10
The Role of Mobile Phones in Increasing Accessibility and Efficiency in Healthcare. Moving the debate forward. The Vodafone Policy Paper Series, Number 4 (Newbury: Vodafone Group Plc, March 2006).
8
16
While developed countries present different economic and cultural conditions from those found in
developing nations, the results of the studies may contain applicable lessons, especially as ‘rich world’
diseases become increasingly prevalent in the developing world. The World Diabetes Foundation
predicts that by 2025, 80% of all new diabetes cases will originate in developing countries, which will
require new approaches for dealing with this and other chronic diseases. Studies conducted in the developed world may also provide useful lessons in monitoring and evaluation, as well as study design.
There remains a need for large-scale evidence of mHealth effectiveness, as measured by long-term,
repeatable improved outcomes in either health or economic terms. Such studies would be particularly valuable in developing country contexts, and sponsors should continue to evaluate progress in
order to establish clear-cut proof of concept and strengthen the case for scaling programs nationally,
regionally, and beyond.
Creating a Framework for Impact Measurement
mHealth programs that define rigorous impact assessment methods will be more likely to secure continuing funding and become sustainable over the long term. A Dalberg Global Development Advisors
study, commissioned by the UN Foundation and Vodafone Foundation Technology Partnership on the
use of PDAs for health information, offers a potential template for determining the effectiveness of current and future mHealth programs. Dalberg worked with the Partnership, the WHO, Ministry of Health
officials in pilot countries, and DataDyne—a non-profit provider of mobile health data solutions—to
develop a theory of change and to conduct a baseline assessment of the test program’s functionality.
The study lays out a process for monitoring the collection and analysis of health data at the local and
regional levels. This approach identified unforeseen technical, logistical, and decision-making problems in the pilot case. For example, it was discovered that the high cost of fuel prevented Ministry of
Health officials from going out to collect data and the short battery life of some PDAs caused a loss
of data. Both of these issues significantly reduced the amount and quality of data available for decision making. Dalberg also monitored the use of data once it was collected, particularly in the context
of health ministry meetings. The study identified instances where the data was not properly integrated
into decision making and described how processes could be improved to ensure that resource allocation decisions are more data-driven. Overall, the study helped to determine both the cost effectiveness of data collection and the outputs that flow directly from the data.
Dalberg notes that monitoring and evaluation efforts can face critical challenges in the short term, particularly with limited budgets to fund such activities. To overcome some of these challenges, it is important to focus first on managing toward short-term outputs, such as how many PDAs are deployed.
The next step is to correlate short-term outputs with actual long-term health impact. This is quite difficult, because the objective is often to measure outcomes that did not occur, such as decreased infant
mortality and disease incidence, or outcomes that occur over the long term. As mHealth applications
improve the process of data collection and the incorporation of data into decision making, this will
provide a foundation upon which to conduct long-term impact evaluations. ■
“It’s important to have an ROI [return on
investment] model that articulates the cost
savings of mHealth, and also to take into account
the economic burden of health. You are trying
to prevent negative health outcomes, and if you
prevent them you can’t easily measure that.”
—Eduardo Jezierski,
Vice President of Engineering, InSTEDD
17
Future Health Needs
Credit: Vital Wave Consulting
Assessing mHealth and Future Health Needs in
Developing Countries
Equally important to the cost-effectiveness and scalability of mHealth is its ability to provide an effective tool for addressing emerging health needs. Health experts note that within the next 15 years, policymakers and health providers in the developing world will be forced to turn their focus to prevention and early detection rather than late-stage
treatment of non-communicable diseases, such as diabetes and cancer, as well as to the health needs of an aging
population.11 These changes are being caused by trends such as migration from rural to urban areas, economic
growth, and changing dietary habits. As developing countries tackle and make significant improvements in the
spread of communicable disease, average income levels increase along with average life expectancy. Even a slight
increase in income contributes to changing dietary habits, and consumption of meat products and processed foods
is linked to the contraction of diabetes and cancer. Late detection of these diseases leads to lower survival rates
and reduced life expectancy, and has negative consequences for social and economic development. Developing
countries are therefore being confronted with a double burden of treating and containing the spread of communicable diseases while combating a wide range of unfamiliar health challenges. Table 1 illustrates these evolving trends.
Current Healthcare Picture
• Communicable diseases.
• Lack of immunizations.
• Lack of safe water sources.
Global & Demographic Changes
• GDP growth increases spending on healthcare.
• Traditional diseases controlled (TB, smallpox)
and new diseases appear (SARS, avian flu).
• Aging populations mean increase in death from
non-communicable causes.
• Declining birth rate and climbing life expectancy.
• Adoption of ‘developed country’ behaviors.
Tomorrow’s Healthcare Picture
• Current health care picture issues
continued.
• Shift from ‘late stage’ treatments to
prevention and early detection.
• Increased focus on health issues of elderly.
• Continued health worker shortages and
distribution inequities.
Table 1. Looking ahead: Evolving mHealth services for evolving health needs.
11
Gutiérrez-Robledo, L.M. Looking at the Future of Geriatric Care in Developing Countries. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 57:M162-M167, 2002.
18
Assessing mHealth and Future Health Needs in Developing Countries
Shift from Communicable to Chronic Disease
Over the next 10 years the cost of diabetes, heart disease, and stroke will take a tremendous
toll on the national incomes of developing world countries. According to estimates by the
WHO, diabetes, heart disease, and stroke together will cost about $555.7 billion in lost
national income in China, $303.2 billion in the Russian Federation; $336.6 billion in India; and
$49.2 billion in Brazil. Even beyond these countries the cost will be significant. The cost of
these diseases for Tanzania in the same period is estimated to be $2.5 billion.12
mHealth is well-positioned to address these challenges using tools currently available. For example, just as
SMS alerts are useful in raising public health awareness of communicable diseases, these same types of
alerts can be used to ensure patient adherence with treatment of chronic diseases such as diabetes. SMS
alerts can be sent out to address chronic diseases and mental health issues in urban areas such as smoking
cessation and nutrition reminders.
Many middle-income countries in the developing world (i.e., Brazil, Argentina, Thailand, Mexico, and Turkey)
are already seeing a shift away from communicable diseases toward chronic diseases (such as heart disease and diabetes). In these countries, there is already evidence that mHealth programs are experimenting
with addressing a wider range of chronic non-communicable diseases, with a focus on early treatment.
12
World Diabetes Foundation. Diabetes Facts. Retrieved on 16 November 2008 from http://www.worlddiabetesfoundation.org/composite-35.htm.
Credit: WFP Susan Schulman
19
The MediNet Healthcare Management System is being
developed by researchers at the University of the
West Indies and Microsoft for monitoring and treating
diabetes and cardiovascular disease. The system will
provide treatment suggestions to patients via mobile
phone text or pre-recorded voice messages.
Evolution of Mobile Technologies
Addressing future health needs will be facilitated by the development of mobile technologies and network
expansion. The key technology trends in mobile technology continue to be the same trends that have characterized technological progress for the past 40 years: miniaturization, greater speed, and cost reduction.
These advances are reflected in mobile telephony by some of the advancement issues shown in Table 2. A
greater range of services becomes possible with more uniform, faster, and more affordable broadband access; greater access and coverage expands the ‘subscriber’ base, building volume, creating incentives for
players, and helping push sustainable mHealth applications beyond simple one-way data services. Ŷ
Current Technology Picture
Key Technology
Advancement Issues
Tomorrow’s Technology Picture
Mobile phones carry range of features
suitable for basic mHealth services and
country varations.
Hardware
Most new handsets access web (GPRS,
other), download pictures and images.
Speed limits applications and
country variations.
WiMAX-type chipset standard
for PCs (Intel, others) becomes
standard.
Increased intelligence blurs distinction
between cell phones and mobile computers.
Solar chargers, larger displays.
Most laptops, handhelds, PDAs easily
access wireless networks where available.
Widely available for laptop and handhelds.
Software/
Applications
Network
Access
Java Virtual Machine (JVM),
Open Systems.
Acceptance of OSS accelerates application
development, reduces cost.
Cellular common in urban, less so in rural.
Greater bandwidth for new
applications.
Network transparency.
Broadband, Internet access limited
NGN, IMT-2000.
Wireless networks create near universal
Internet access.
Spreading IP access for
standards, licensing
decisions.
Greater range of services, provider
partnerships permitted.
Only recent availability for handsets as
vendors open architecture.
geographically, costly.
Standards
Broadband, Standards may require policy
decisions.
Education/awareness programs.
Services
More sophisticated diagnoses/consultation,
e.g., teleradiology, teleopthamology.
Medication monitoring.
More effective use of healthcare workers.
Data collection services.
More ‘personal’ mHealth services.
Disease tracking.
Services for travel-restricted.
Remote monitoring.
Table 2. Evolving mobile technology capabilities.
20
Sustainable and Scalable
Identifying the Building Blocks for Sustainable
and Scalable mHealth Programs
Success can beget success in the field of mHealth if organizations enhance their opportunity to drive
successful outcomes by learning from similar projects taking place within the mHealth ‘ecosystem.’ This
section identifies mHealth projects that embody practices of highly scalable and sustainable mHealth
programs. The case studies reveal some of the key benefits of mHealth, and provide examples of how
to structure successful mHealth initiatives. These case studies also reflect the field’s dynamism, as each
was implemented within the 12 months prior to the publication of this report.
Key Building Blocks for Success
As a young field, mHealth is well positioned to benefit from best practices and available technology
documented in early project reports. The case studies of mHealth projects and input from industry
experts reveal common practices that collectively form the building blocks for success in this young,
dynamic field.
Forge strong partnerships
Partners from multiple sectors bring diverse strengths to the project. Ensuring that each partner advances its organizational goals through the project paves the way for successful future
collaborations.
Be accessible
Communication is more effective when tailored to specific social, ethnic, and demographic
groups. Colloquial language and references to pop culture may be effective in reaching teenagers, while older populations may prefer a more formal approach.
Design with the end user in mind and maintain a focus on usability
Applications and devices must take the users work environment into account in the design
phase. In the mHealth environment, ease of use is essential.
Build a long-term funding plan
Continuing the project beyond the initial seed funding can be accomplished by aligning with
long-term national health goals. Integration with the national health care program of the country of operation is essential.
Set measurable goals
By setting interim goals and benchmarks, mHealth projects can provide proof of success, allowing them to secure support and funding for expansion. Setting measurable goals also helps
project principals to identify the need to quickly correct a particular course of action in the
event that interim targets are not met.
Collaborate with other mHealth organizations
With dozens of projects currently operating, the mHealth field is now in a strong position to
move forward by sharing techniques and applications. Organizations such as the Open Mobile
Consortium are facilitating the ability of the field to move forward by sharing best practices.
Identifying the Building Blocks for Sustainable and Scalable mHealth Programs
21
#ASE3TUDYs0ROJECT-ASILULEKE
Credit: DataDyne
Project Masiluleke
Country: South Africa
Sponsoring Organization and Partners:
Pop!Tech Accelerator, Praekelt Foundation, iTeach, frog design, MTN, Nokia Siemens Networks, National AIDS
Helpline, National Geographic Society, Ghetto Ruff Records, Children of South African Legacies, Aricent
The Project
Incubated by the Pop!Tech Accelerator, Project Masiluleke is designed to harness the power of mobile
technology as a high-impact, low-cost tool in the fight against HIV/AIDS. Under the guidance of an international,
multidisciplinary team, the project provides a suite of interventions targeting the entire HIV/AIDS care continuum
by promoting testing, treatment connection/adherence and, ultimately, improved access to testing via an
innovative home HIV test kit supported by mobile counseling.
Project Masiluleke is currently sending one million text messages per day throughout South Africa that encourage people to be tested and treated for HIV/AIDS. By capitalizing on the ubiquity of mobile devices in even the
most resource constrained areas, this project has the potential to revolutionize the public health response to
HIV/AIDS in South Africa and other parts of the globe. The model is designed for scale and replication and can
be modified to address a variety of public health and social challenges.
Messages are written in local languages, and are used to direct recipients to the National AIDS Helpline. Once
patients have called, representatives of the hotline provide information about testing services and locations.
Be Accessible
With many countries having multiple local and regional languages, communicating with
people in the language they know best is critical. Similarly, it is essential to understand the
target demographic. Colloquial language and references to pop culture may be effective in
reaching teenagers, while older populations may prefer a more formal approach.
22
#ASE3TUDYs0ROJECT-ASILULEKE
Objectives and Results
Project Masiluleke is designed to make more people aware of their HIV status because in South Africa, onequarter of the population is estimated to be infected with HIV, but less than 3% know their status. The broader
goal of the program is to have those infected receive treatment and to halt the spread of the disease. Initial
results from a beta test of the project indicated that it helped to nearly triple call volume to the helpline in the
three weeks during which it ran. The project partners are building in rigorous monitoring and evaluation of the
project by, for example, linking calls to the helpline to PCM text messages through the use of distinct phone
numbers that allow organizers to verify the number of calls generated by the program. Once the project is
operating successfully, the system will be expanded to provide information about TB resources and treatment.
Future Plans and Scaling Challenges
The next phases of the project will be the use and extension of the Praekelt Foundation’s TxtAlert program to
remind HIV-positive patients to take their medication and keep medical appointments; the creation of ‘virtual’
call centers staffed by highly adherent patients; and the deployment of easy-to-use home HIV test kits, as the
social stigma attached to HIV often prevents people from going to public clinics for testing.
Challenges remain for scaling projects like Masiluleke. Working across multiple networks, developing relevant
messaging, and catalyzing resources to take the initiative to scale are all difficult, according to Robin Miller of
Praekelt Foundation. Yet the project’s early achievements point to some factors that increase the likelihood of
success. Miller says that several ingredients have been critical for success:
■
Ensuring strong local partners to develop relevant content. Masiluleke’s partners enable
the organization to tap into an already established customer base and also leverage their knowledge to
build valuable content.
■
Method of interacting with the intended audience. “We have found that mobile phone innovations already exist, even without new applications. For example, sending ‘missed calls’ led to the creation
of the PCM message which was the starting point for the project.”
■
Scaling and progress are only possible through rigorous data collection and
analysis. Only through measurement can we know what is working and where redirection is needed.
23
Credit: UN Mark Garten
Multiple Health Issues Addressed by SMS Campaigns
Netcare Vodacom Smile for You Campaign—Hundreds of thousands of children in the developing world are afflicted with the condition known as cleft lip and palate, a relatively common birth defect that is all but invisible in
rich countries where surgery to correct it is widely available and affordable. Children who are not able to have
this condition remedied through surgery often have eating and speech difficulties and face social discrimination. In 2007, the Netcare Group, a private medical hospital group in South Africa, and Vodacom teamed with
the Praekelt Foundation to offer 50 free cleft lip and palate surgeries to children too poor to afford them. A
previous campaign to raise awareness of this service had relied on traditional media such as print and radio
but yielded disappointing results, with only about 12 candidates identified for the surgery.
For the Smile for You campaign, the sponsors shifted to a mobile technology solution to improve response
levels. In South Africa, ‘Please Call Me’ (PCM) text messages, which mobile phone users can send for free with
a request to the sender to call, have become an enormously popular service, and operators subsidize them
through the sale of advertising space in the unused character space of the text message. Over the course of
five days, Vodacom donated space in one million PCM text messages for a message asking recipients if they
knew of children in need of free cleft lip and palate surgery, using Praekelt’s SocialTxt technology (also used in
HIV/AIDS outreach efforts). During the first two days, recipients who wanted more information were prompted
to phone a call center manned by Netcare staff. Beginning on the third day, recipients were given the option
of sending an SMS with the word ‘SMILE’ to the Netcare call center, whereupon a representative would phone
them to provide further information about the surgery offer (resulting in a lower cost to the message recipient).
The results of the campaign demonstrated the effectiveness of this concept. Calls made to the call
center, which hovered in the single digits in the weeks before and after the campaign,
averaged nearly 35 per day, while staff received over 355 text messages during the
three days that responding via text message was an option. In all, 42 children were
identified as surgery candidates, more than three times the number identified during a
traditional media campaign lasting six weeks. The sponsors note that 203 people who did not know
anyone with a cleft lip or palate responded, indicating that broadening the campaign to include languages
other than English might yield even more promising results.
According to the Praekelt Foundation, several factors were essential to the campaign’s success. All of the
partners involved in the project brought strengths to it, as well as a desire to rigorously track results. The willingness to change tactics in the middle of the campaign also allowed the sponsors to compare communication
methods in order to determine what was likely to work in future campaigns. And perhaps most critically, the
partners leveraged the popularity of PCM messages and the experience Praekelt had accumulated in previous
campaigns using SocialTxt software.
24
#ASE3TUDYs4EXTTO#HANGE
Text to Change (TTC)
Country: Uganda
Celtel, AIDs Information Centre (AIC), Merck, and the Dutch Ministry of
Foreign Affairs
The Project
Text to Change (TTC) provided HIV/AIDS awareness via an SMSbased quiz to 15,000 mobile phone subscribers during three months in
Uganda. TTC was founded with the goal of improving health education
through the use of text messaging, which holds the advantages of anonymity and strong uptake among
the population. Partnering with the mobile carrier Celtel and the local NGO AIDS Information Centre (AIC),
TTC conducted a pilot program from February through April 2008 in the Mbarra region of Uganda, with the
objective of increasing public knowledge of and changing behavior around AIDS. The program aimed to
encourage citizens to seek voluntary testing and counseling for HIV/AIDS.
An SMS-based multiple choice quiz was administered to 15,000 Celtel mobile phone subscribers in the rural
region of Mbarra. Free airtime was offered to users to encourage participation in the program; this was determined to be a powerful incentive since users can exchange the airtime with other subscribers as a type
of currency.
The quiz was interactive. When participants gave a wrong answer they received an SMS with the correct
answer from the cell phone provider. The uptake rate of the survey was 17.4% and focused on two specific
public health areas:
■
General knowledge about HIV transmission
■
The benefits of voluntary testing and counseling
At the end of the quiz, a final SMS was sent to motivate participants to go for voluntary testing and counseling at the local health center. Those who went to the center were asked a final question: Was this was
the first time they had an HIV test? After testing, participants were requested to leave their mobile phone
number so that post-test counseling could be arranged. For the people who came to the health centers
through TTC, HIV testing and counseling was free of charge. Initial grants from Merck, the US pharmaceutical company, and the Dutch Ministry of Foreign Affairs supported the program launch.
Text to Change (TTC) provided HIV/AIDS awareness
via an SMS-based quiz to 15,000 mobile phone
subscribers during three months in Uganda
Forge Strong Partnerships
Successful mHealth projects require the participation of partners with expertise in the fields of technology,
healthcare, and academia. Validation and testing are key steps in the conception of mHealth programs and this
phase typically occurs within a university setting or a technical organization. In order to move to the implementation stage, however, it is essential to bring other partners into the project. Dr. Patricia Mechael of the Earth Institute notes that “The projects that have been implemented at significant scale have forged strong partnerships,
either with a government or a private corporation.” Mechael further affirms that the mHealth field currently finds
itself in a place where a number of projects are in the design and testing phase that have not yet made the move
to implementation. “As the diverse sectors involved in mHealth continue to collaborate and the corporate and
political climate become more supportive we expect to see more projects move into the implementation phase.”
25
Set Measurable Goals
As with any initiative, setting measurable goals establishes the barometer that allows mHealth projects to assess
success or failure. It builds in the rigor that is required if
course corrections are needed during the project. Once
achieved, these goals, in turn, form the building blocks
for success, allowing the project to move forward with
larger implementations and broader partnerships.
Credit: Text to Change
The quiz produced a 40% increase
in patients who came in for
testing—from 1,000 to 1,400 during
a six-week period.
The quiz had two goals:
■
Collect information. In particular, the program was able to assess the rate of correct or incorrect answers
within certain socio-economic sectors, and pass this information along to UNICEF.
■
Promote testing and counseling. The quiz notified participants of the location of the nearest testing
center. If they stated that they were referred from the quiz, testing was free (there was normally a small
charge for testing).
The quiz produced a 40% increase in patients who came in for testing—from 1,000 to 1,400 during a six-week
period.
In terms of information gathering, a key finding of the survey was that although people were quite knowledgeable about issues such as condom use, they did not think that AIDS testing was accurate or anonymous. This
was a major finding, in that the population of Uganda had not been surveyed on this question before. TTC was
able to pass this along to larger health agencies operating in the region, thereby contributing to the efficacy of
existing health programs.
TTC co-founder Hajo van Beijma notes that “there was initially an element of risk for the funders since this
type of project had not been conducted before, but now that we have proven results we have the opportunity to expand.” TTC is planning a follow-up program in Uganda in January 2009. One of the goals of this next
campaign is to promote the safety and effectiveness of the testing center, and therefore specifically encourage testing.
In this phase, collaboration with local partners will be further strengthened, with the local HIV/AIDS organizations submitting questions. Text to Change intends to shorten the duration of the program to four weeks, hoping to minimize participant drop-out rates, and to include non-English speaking subscribers by enabling them
to read SMS messages in their local languages.
The pilot saw the sponsoring partners benefit as well: Celtel (now rebranded Zain) reaps benefits not only
from a corporate social responsibility (CSR) perspective but also through the promotion of its texting service.
The testing center increased the number of tests conducted, placing them in a position to receive expanded
funding.
26
Future Plans and Scaling Challenges
Hajo van Beijma hopes to build upon lessons learned from the pilot. He comments, “After the pilot we
saw that our initial program didn’t have a good survey running. In the second round we developed a new
survey with Ugandans, and used university students. Their IT knowledge is fabulous. They really know how
to program these kinds of software tools in Uganda.”
The new program in January 2009 will target 30,000 people, and ultimately TTC plans to do a nationwide
roll-out. Van Beijma notes, “If we are able to prove that we can send out a large number of questions, that
will lay the groundwork for the nationwide program. In the first pilot there were some issues with being
able to send out a large number of questions at the same time.”
Van Beijma cites several critical success factors for scaling Text to Change and similar mHealth projects.
These include:
■
Develop surveys in the numerous local languages. This would make their message more
accessible to specific ethnic and social groups. Literacy is also an issue. However, van Beijma notes,
“If people do not speak or read English and they get a text message they will ask their neighbor what
it means.”
■
Secure ongoing funding. Though TTC is more cost effective than many other education programs, steady funding will allow for stable operations and growth.
■
Collaborate with other mHealth organizations. Van Beijma notes that one of the consensus findings of the recent MobileActive conference in South Africa (October, 2008) is the need to
set up a consortium to promote collaboration among mHealth organizations in different developing
countries. “The goal is to work with organizations that are doing similar and complementary things in
different countries. This way if we move into other countries we will combine strengths, for example,
by developing software together.”
Credit: Text to Change
27
#ASE3TUDYs$ATA'ATHERING
$ATA'ATHERING
Country: Brazil
Nokia, Amazonas State Health Ministry
“In order to stop an outbreak and the
means of disease transfer, we need
to have the information very fast.
That’s the only way to prevent the
virus of dengue from circulating.”
—Luzia de Melo Mustafa,
Health Agent coordinator, Amazonas Brazil
The Project
In the Amazonas state of Brazil, containing dengue fever is a constant challenge due to heavy rainfall during
most of the year, and local methods for storing water in homes—both of which have been shown to promote
mosquito breeding. The state health department must warn households constantly about the dangers of behaviors that encourage mosquito proliferation. Despite these difficulties, the state is one of the most efficient
at containing the spread of the virus relative to other states in Brazil, due partly to its partnership with Nokia
on the Data Gathering mHealth initiative.
The Nokia Data Gathering system enables fast and effective data collection, which is essential to containing
the spread of the dengue virus. Development of the software began in the first quarter of 2007 and it was
piloted in different regions of Brazil during that same year. The Amazonas Health Department undertook the
first full implementation of the solution, which began in October 2008.
Data Gathering allows the creation of customized questionnaires, which are distributed to the mobile phones
of health agents in the field. When the field workers finish their surveys, they send the data back to the server
via a wireless connection, from which it can be integrated into the organization’s existing systems for immediate analysis. Data Gathering also provides GPS location information for each record, which would otherwise
require dedicated instruments.
Users report the tool is flexible and easy to use. As Luzia de Melo Mustafa, an Amazonas health agent, affirms, “It’s easier, quicker and more practical. You type it and send it right away, it goes straight to the server.
Then the data is consolidated and we can get the result immediately and, consequently, we may take the
right actions, what we need to do. The devices are providing us with precision; the information we need to
develop [effective responses] in the areas where the infection levels are high.”
The goals of the project are all about saving time to save lives. Andre, project principal, states “The initial
impetus for the project started with a meeting in Brasilia with the federal Ministry of Health where we tried to
find a way to use mobile technology to improve current health data surveys being conducted using pen and
paper. There was a real need to make the process more agile and more reliable, providing the government
with a tool that could ultimately save lives through the use of smartphones.”
Results of Data Gathering implementation to date are highly encouraging. The project team’s preliminary
evaluation has shown that the time spent in data gathering was drastically reduced, and end-user acceptability has been very high so far. Even before the full implementation, more than 400 results were gathered
during the tests by a team of 20 field professionals in the course of two days, all with GPS information. Luzia
de Melo confirms, “Before we used to wait for one or two months before we could get all the consolidated
information. Now, we have it on a daily basis.” As Greg Elphinston, Community Involvement Director for
Nokia, elaborates, “If you have to wait two to three months for information in the health context, this can be
the difference between life and death.”
More than 400 results were gathered during the tests by a team of 20 field
professionals in the course of two days, all with GPS information. Luzia de
Melo confirms, “Before we used to wait for one or two months before we
could get all the consolidated information. Now, we have it on a daily basis.”
28
#ASE3TUDYs$ATA'ATHERING
Future Plans
Plans for expansion will be based on a comprehensive evaluation of current work. The immediate growth
objective is to broaden the covered areas in the Amazonas state, as well as adding yellow fever and malaria
to the list of diseases to be surveyed.
Project staff cite several critical success factors for Data Gathering and similar projects, including:
■
Work closely with local and regional government agencies. The service must respond to
the local needs as perceived by local officials. Their support for the project will make implementation and
expansion possible.
■
Maintain a focus on usability. According to Andre Erthal, Head of Community Group at the Nokia
Technology Institute, “If the field agents do not see the device as part of their work or have difficulties in
using it, it may severely damage the overall success of the implementation. That is one of the reasons
why the solution was developed since the beginning with the end user in mind, so we could develop the
solution to be as user-friendly as possible.”
■
Working in partnership with Nokia, Pan American Health Organization (PAHO), and National Foundation
for Indigenous Peoples’ Health (FUNASA), the UNF-VF Technology Partnership will be launching a program called Mobisus in Brazil in 2009, utilizing mobile phones for health data gathering.13
Design With the End User in Mind
“End-user acceptance is one of the critical success factors for the project. If the
field agents do not see the device as part of their work or have difficulties in using
it, it may severely damage the overall success of the implementation. That is one of
the reasons why the solution was developed since the beginning with the end user
in mind, so we could develop the solution to be as user-friendly as possible.”
—Andre Erthal,
Head of Community Group, Nokia Technology Institute
Government Support is Critical for Long-term Success
The majority of mHealth projects are implemented with seed funding from philanthropic organizations such as foundations and multilateral institutions, or as part of a corporate social responsibility initiative by a for-profit business. The three case studies highlighted in this report
provide proof of concept, and initial positive results. However, all too often, once the initial
funding has been exhausted the projects find it difficult to achieve scalability and sustainability, resulting in unintended termination. Ensuring long-term sustainability is a major challenge
for mHealth projects.
Expert researchers in the public health and eHealth arena are currently examining the
sources of sustainability for mHealth projects. In particular, Dr. Adesina Iluyemi, a PhD Candidate at the University of Portsmouth, United Kingdom focusing on sustainable mHealth in
developing countries, has noted that mHealth projects are far more likely to be sustainable in
cases where buy-in from governmental or public bodies is secured. In this way, the project is
institutionalized into existing government health programs and can receive budget attention.
Dr. Iluyemi notes, “It is very important that a mHealth project have the support of the national
or regional government. The majority of mHealth projects are currently funded by international agencies or CSR initiatives of companies. The problem is when the funding runs dry
there is no more continuity. In the long term the custodian of the project will be the government. This could be national, local, or regional. During the lifetime of the pilot project it is very
important to ensure that the government buys in and that the government sees the benefit
so that the project can survive beyond the donor-funded period.” For every mHealth project,
therefore, it is critical to ensure that the program is aligned with the strategic goals of the
national health system.
13
http://commitments.clintonglobalinitiative.org/projects.htm?mode=view&rid=211710.
29
Open Source Movement: A Building Block for mHealth Success
A component of sustainability for mHealth programs is building capacity to enable programs to be locally
implemented and maintained. The most successful mHealth projects have obviated the need for external
consultants and achieved technical self-sufficiency. For many organizations, open source software is a tool
for self-sufficiency, as it reduces costs, increases the available pool of programmers, and eliminates the need
for outside consultants. It also encourages innovation.
Software development costs can be reduced with open source software because there is no need to purchase licenses. Because local programmers in developing countries are increasingly being trained in open
source software, self-sufficiency is promoted. According to Dr. Balcha Masresha of the WHO, open source
software is a key variable in the ability of EpiSurveyor, a PDA-based data collection project, to be sustainable
and scale up to 20 countries in sub-Saharan Africa. “It is crucial for this kind of project because of existing
longstanding experience with the EPIINFO software (freeware developed by the Centers for Disease Control)
used in nearly all countries for the management of immunization and surveillance databases and analysis,
and because of the inhibitive costs involved in the purchase of proprietary software for the average African
user.”
As Eduardo Jezierski, Vice President of Engineering at InSTEDD states, “Open source allows different projects to ‘talk’ to each other. In this way we can pool our very limited engineering resources and say ‘here’s
the source code, can you help me with this.’ It is allowing us to create a platform that costs less money from
a licensing perspective for the countries running mHealth programs.” Jezierski further notes that “This industry is at an early stage, and it is very encouraging that people are learning from each other and are sharing
source code. It is very rare that an industry starts with this sort of collaboration.”
Collaborations of this nature are steadily emerging in the mHealth arena—witness the ‘Open Mobile’ Consortium, which was conceived at the MobileActive08 conference in Johannesburg, South Africa in October 2008
and began to take shape in a series of meetings in New York the following month. The organization will focus
on developing best practices and standards for the mHealth field. Organizations of this type will pave the way
for coordinating the various components of mHealth on a grander scale, bringing the industry to a higher
stage of evolution. ■
“It is crucial for this kind of project because of existing longstanding
experience with the EPIINFO software (freeware developed by
the Centers for Disease Control) used in nearly all countries for
the management of immunization and surveillance databases
and analysis, and because of the inhibitive costs involved in the
purchase of proprietary software for the average African user.”
OpenROSA
With so many community-based organizations involved in creating mHealth applications and a need for
both customization and standardization, it is not surprising that many applications are created in an open
source framework. With this in mind, a coalition of community health organizations and health researchers
created OpenROSA in 2007. OpenROSA is a consortium that develops “open source, standards-based tools
for mobile data collection, aggregation, analysis, and reporting.” With university partners in the United States
providing technical expertise and community health professionals in Africa testing and deploying mobile applications in the field, multiple organizations are able to share their ideas, data, code, and experiences.
As part of this effort, OpenROSA is currently developing JavaROSA, a J2ME implementation intended to
run on mobile phones and PDAs. One of the programs using this architecture is CommCare, which is being
tested in Tanzania and Uganda by community health workers collecting health data in rural areas. The program was designed to maximize patient data security while remaining simple for workers to use, a difficult
balancing act. Participants in the project hope that as CommCare is deployed, it will not only provide better
data and improved patient care and service where it is used, but that the lessons from field experience will
help perfect the architecture for future projects.
30
Incentives
Credit: ENACKQT
Understanding the Incentives for Multiple
Players: mHealth Value Chain
One of the most crucial building blocks for successful and sustainable mHealth programs is to forge strong
partnerships, particularly across sectors (for-profit, non-profit and public sector). A solid understanding of
the needs and interests of these multiple players is required in order to marshal their energy and resources.
One method of identifying these incentives is through value chain analysis, or an evaluation of the relationship
between all organizations and steps in the commercialization or delivery process of a product or service. The
diverse players—spanning from the patient to the equipment vendor—in the mHealth value chain are listed in
Table 3.
Value Chain Models for mHealth: One-way Data Applications
Figure 5 illustrates the most basic set of relationships and players for mHealth solutions based on a oneway messaging application. Examples of this type of application include medication regimen adherence and
monitoring programs (e.g., SIMpill, which equips pill bottles with a SIM card and transmitter to track medication adherence) and education and support programs based on one- or two-way SMS alerts (FrontlineSMS,
a platform for sending and receiving group SMS messages; MyQuestion/MyAnswer, providing education on
HIV/AIDS via SMS communications). Figure 5 depicts the dynamics and incentives described in Table 3.
Player
Incentive
Patient or Citizen (Mobile Subscriber)
Improved health outcomes
Health Care Provider
More efficient and effective delivery of health services
NGO
Advance organizational mission, attract funding
Foundations
Advance organizational mission
Government
More efficient health care provision, effective government
Equipment Provider
Device revenue generation, improved brand recognition
Service Provider
Revenue from service fees, increased subscriber base
Application Solutions Provider
Revenue from additional applications license fees
Content Management
Increase in volume of readership or revenue
Platform Provider
Revenue from sales
Table 3. mHealth value chain players and incentives.
Value
Understanding the Incentives for Multiple Players: mHealth Value Chain Understanding the Incentives for Multiple Players: mHealth Valu
31 uue Chain
Considerations about project scale are crucial in planning for long-term project sustainability. Scale is a principal factor in the incentive structure of many value chain participants. For example, it is unlikely that project
leaders will be able to obtain ongoing funding for special device modifications or customized features for small
local initiatives, since there is not enough volume to warrant contributions from the platform developer without
prohibitive development and maintenance fees. On the other hand, a basic ‘one-way’ messaging service can
be an attractive investment even at low volumes, as it significantly reduces costs and improves efficiencies for
health care providers, enabling the phase-out of cumbersome manual processes.
However, at higher levels of scale, a program can represent strategic growth for the larger value chain participants (those on the left side of Figure 5). Partnerships that are rooted in the business interests of for-profit
participants have an intrinsic value beyond corporate social responsibility (CSR) and, therefore, are less at risk
of being cut off during a downturn in the participant’s overall business.
Delivery of services,
operational efficiencies,
program expansion,
achieving mission
Equipment Vendor
Doctor/
Health
Provider
Revenue (short- and long-term), brand
and business development, opportunities
for network expansion projects
Project
Management
Application/
Solution Developer
Home
Monitoring
Device
Operational efficiencies,
healthcare
Revenue (short- and long-term)
Platform Operator
Mobile
Subscriber
Revenue (short- and long-term)
Mobile
Service
Provider
Revenue (short- and longterm), expanded user base
Scale Required for Sustainability
High
Medium
Low
Figure 5. Value chain model for ‘one-way’ mHealth applications.
32
Understanding the Incentives for Multiple Players: mHealth Value Chain
App
Developer
Hardware Vendors
Patient
Internet
Laptops
Ministry of
Health
Project Owner/
Developer
Mobile Service
Provider
Funders
Health Workers
Regulatory
PDAs,
Handsets
Platform
Developer
Banks
Patient
Patient
Patient
Patient
Content Providers
NGOs
Patient
Content
Aggregators
Health Systems
EHRs, Other
Databases
Content
Developers
Figure 6. Value chain model for ‘two-way’ mHealth applications.
Value Chain Models for mHealth: Two-Way Data Applications
Figure 6 presents a value chain model for a more complex service offering—a two-way data application.
Two-way applications are developed for data access programs such as remote data collection, access to
client records, access to health information databases, census taking, and electronic health records creation and storage (e.g., EpiSurveyor, a survey program for remote data collection). While it is not likely that
two-way services will have the volume potential of one-way services, these services appeal to potential
participants because they are Internet-based. Participants in the value chain may find incentive to integrate
mHealth solutions with growth plans around Internet access, as it is an established functionality on both
phones and laptops and the basis for other services (and thus revenue opportunities).
The complexity evident in Figure 6 creates opportunities for innovative health solutions, but also a number of
challenges, including increased dependence on information technology (IT) infrastructure, the need for more
sophisticated application development, greater support service requirements, and a more expensive hardware component. These higher-level solutions entail higher project cost and participant involvement, which
in some cases may be prohibitive.
With more value chain participants and higher costs of execution, there is less reward (whether in the form
of revenue gains or operational efficiencies) to go around. It therefore becomes progressively more difficult
to achieve the financial impact that provides momentum and leads to partnership with larger players. These
companies’ contributions to the more ambitious initiatives, therefore, will likely be limited to the provision of
standard services or as a one-off CSR project. ■
Understanding the Incentives for Multiple Players: mHealth Value Chain
33
A Call for Action
Credit: UN Foundation/Nothing But Nets
A Call for Action
The mHealth field offers opportunities for players across multiple sectors, from governments to businesses
to NGOs. By taking a strategic approach, each of these players can advance their organizational objectives
while contributing to improved health outcomes on a massive scale.
Operators
Combine mHealth with delivery of other mServices
Operators can capitalize on the popularity of mServices in developing countries to build support for mHealth
initiatives. Rapidly growing mServices such as mBanking and mCommerce are proving the viability of mobile
technology as a service model. Packaging such services with mHealth solutions creates economies for
operators and takes advantage of shared resources and best practices. It also presents a more compelling
proposition to end users by serving as a ‘one-stop shop’ for all their needs.
Leverage handset maker relationships
Mobile operators have tremendous influence and strong relationships with handset manufacturers, and they
should leverage this position to bring to market phones and other devices that can provide the mHealth and
other mobile services consumers in developing countries need. Affordability is critical, yet not sufficient to
significantly increase the usage of mServices across the developing world. Low-cost phones that incorporate simple, innovative features are key to increasing access to mServices and helping to create the scale
and market needed to sustain them over the long run.
34
A Call for Action
Be pro-active in developing joint solutions
Operators would do well to pro-actively seek out opportunities to improve health outcomes by initiating
public-private partnerships, teaming up with governments and NGOs to address pressing national health
issues, and collaborating with software providers to develop targeted healthcare solutions. Joint projects help
ensure that key stakeholders are on board, increasing the potential for successful outcomes.
Enhance mHealth infrastructure
Infrastructure conditions vary in the developing world, and operator services geared toward mHealth can
enhance their networks to facilitated increased mHealth activity. As Eduardo Jezierski, Vice President of Engineering at InsteDD notes, “From a technical perspective you need to think not just about use of your network
as a way for humans to communicate with humans but also as a way for humans to communicate with systems and information. The challenge is to build better application gateways that allow for different organizations involved in mHealth to build the applications themselves.
.'/S
For best results, think big and join forces
Think big. As Jesse Moore of the GSMA states, “Scale is of utmost importance to mobile operators. Operators evaluate value-added services, such as mHealth applications, by volume and volume is measured in millions of users, not hundreds or thousands. Scale is evaluated on three dimensions: how easy is the service to
use by the end users? How easy is it to install and maintain on the operator’s network and how many handsets can use the service (many handsets in Africa are very basic and hence the service must be designed for
simple handsets). Without scale, the mHealth application will be evaluated as a corporate social responsibility
initiative and its sustainability will be in question.”
Partner
The most effective approach to
achieving scale is to join forces
with companies that are already
offering mServices (mobile money,
mobile government services,
mobile education), and propose
a joint effort on mHealth. NGOs
bring valuable assets to the
table—they understand the local
environment and how to design
services with cultural and behavioral patterns in mind. NGOs also
have feet on the ground and can
assist with training and education
around the mServices. In return,
they can use the existing technology platform to launch mHealth
initiatives.
Design With the End User in Mind
Operators
■ Combine mHealth with delivery of other mServices
■ Leverage handset manufacturer relationships
■ Be pro-active in developing joint solutions
■ Enhance mHealth infrastructure
NGOs
■ For best results, think big and join forces
■ Partner
■ Provide proof of concept by using the simplest available technology
Policymakers
■ Define an mHealth policy and provide incentives
Funders
■ Ensure project sustainability
■ Provide resources for impact assessment
A Call for Action
35
Provide proof of concept by using the simplest available technology
Many operational mHealth programs build on the broad use of standard cell phones. Early applications provide data access and exchange in the form of one-way or basic two-way services. The infrastructure for these
applications is already in place through standard telecommunications networks, and, unlike more complicated
devices such as PDAs, users have widely embraced the functionality. These simple applications thus have
the distinct advantages of lower start-up and operating costs and broader reach, pointing to a clearer path
toward financial sustainability.
Policymakers
Define an mHealth policy and provide incentives
Define what mHealth means within the national health system. mHealth applications can be designed as an
integral part of the overall health information system, and policymakers are in a unique position to shape these
efforts. One of the most important roles to play in this regard is in driving innovation through incentives. Incentives can include tax rebates to telecom providers for provision of mHealth services, and funding for universities and research institutes studying mHealth solutions.
Funders
Provide resources for impact assessment
Help grantees help themselves. Non-profit and international development funding sources are placing a growing emphasis on ‘demonstrable impact.’ As such, mHealth proposals and programs need to be able to specify
and measure program success. This is even more critical given the early stage of the mHealth market and
the attendant absence of a body of research to which program managers can refer. To mitigate this problem,
funders can set aside funds to enable independent researchers to conduct rigorous evaluations of mHealth
programs.
Ensure project sustainability
Partner with national governments once the initial pilot phase has been completed. By ensuring that mHealth
projects are integrated into government health programs, funders gain long-term sustainability and greater
health impacts for their projects. Academic researchers affirm the central role of long-term financial planning:
Dr. Adesina Ilyumi of the University of Portsmouth states, “Foundations should incorporate sustainable business/financial models beyond donor funding into their strategic plan, and engage with government bodies at
the level of implementation in order to ensure that the project continues beyond the seed funding.” ■
“In today’s mHealth environment there’s a general tendency to try and seek out
solutions to the bigger health problems. Easier ‘low-hanging fruit’ are often
overlooked. Enhancing basic communications within rural healthcare networks
is a classic low-hanging fruit…Communication is fundamental to all NGO
activities, particularly those working in the kinds of infrastructure-challenged
environments often found in the developing world. Hospital staff often lack basic
communication with their community healthcare workers…creating considerable
inefficiencies in the use and allocation of scarce resources. We need to ensure
that we address some of the simpler mHealth challenges…in parallel with our
search for solutions to what we consider to be more complex problems.”
—Ken Banks, Founder,
kiwanja.net
36
A Call for Action
Looking Forward
Credit: UNICEF
Conclusion: Looking Forward
The field of mHealth is at an inflection point. With dozens of projects implemented and proven benefits, all
trends indicate that investment will continue and mHealth projects will serve an ever wider range of constituents in the years ahead. At the same time, technological innovations will bring enhanced benefits, particularly in the areas of data collection, patient monitoring, and remote diagnostic and treatment support, where
application development is already proceeding at breakneck speed.
Health needs in the developing world are rapidly evolving to include chronic diseases, in addition to the
communicable diseases most often associated with developing countries. mHealth is well-positioned to address these challenges using currently available technology. For example, SMS alerts can be equally useful
in raising public health awareness of HIV/AIDS and in ensuring patient adherence to treatments for chronic
diseases such as diabetes. Emerging technologies, such as wide-area wireless systems, will also be an asset in tackling today’s health challenges and those of tomorrow.
As this paper has shown, mHealth projects are operating in a wide variety of developing countries and
providing demonstrable impacts. Documented results—in both the developed and developing world—reveal
that mobile technology improves the efficiency of healthcare delivery. The next stage in the evolution of
the mHealth field is to increase the scope and scale of operations. By learning from examples of similar
projects, mHealth organizations will enhance their opportunity to scale and increase their health impact.
Case studies detailed in this paper reveal some of the key benefits of mHealth and provide examples of
how to structure successful mHealth initiatives. These studies also reveal key building blocks of success for
mHealth projects, such as forging strong partnerships and designing with the end user in mind.
Understanding the Incentives for Multiple Players: mHealth Valu
Value
37 uue Chain
The transformational power of mobile networks and devices is helping drive the adoption of scalable and sustainable health initiatives, particularly in the developing world. To move forward, leading players in the field of
mHealth agree that multi-stakeholder collaboration on a global level is needed.
Due to its nascent stage, mHealth presents a tremendous opportunity to create a global facilitation body,
enabling maximum innovation and impact on global health. There is an agreement among participants in
this arena on the need for a body to address the many informational and logistical gaps in the mHealth ecosystems; from basic market research to best practices; from policy engagement and standards advocacy; to
support scalable implementations of mHealth pilot programs through public-private partnerships.
An alliance cultivating the cross-sectoral and pan regional partnerships and projects necessary to expand the
existing embryonic mHealth ecosystem would be a significant step in enabling closer collaboration on mHealth
initiatives by multi-sectoral organizations.
The long-term goal and expectation underlying all these efforts is that mHealth programs will have a significant
and lasting positive impact on health outcomes such as reduced infant mortality, longer life spans, and decreased contraction of disease. This report is designed to move the field one step further in the achievement of
this ambitious goal by outlining the current state of the field, highlighting mHealth initiatives taking root around
the globe, and outlining the building blocks required for successful and sustainable mHealth initiatives. ■
Credit: DataDyne
38
Compendium
Credit: UN Mark Garten
Compendium of mHealth Projects
The mHealth project case studies are organized by primary application area, from least specialized (education and awareness) to most specialized (diagnostic and treatment support). Although several projects offer
multiple applications, they are categorized here by their more specialized function.
1.
Freedom HIV/AIDS Project, India
2. Learning about Living, Nigeria
3. HIV/AIDS Video Distribution by Mobile Phone, Georgia
4. HIV Confidant, South Africa
5. Project Masiluleke, South Africa
6. Text to Change (TTC) – HIV Prevention through SMS Quiz, Uganda
7. Cell-PREVEN, Peru
8. Community Accessible and Sustainable Health System (Ca:sh), India
9. Community Health Information Tracking System (CHITS), Philippines
10. Dokoza System, South Africa
11. EpiHandy, Uganda, Zambia, Burkina Faso
12. EpiSurveyor, Kenya, Uganda, Zambia (and 20 countries in sub-Saharan Africa by end of 2008)
13. Integrated Healthcare Information Service through Mobile Telephony (IHISM), Botswana
14. Media Lab Asia – Shared Resource for Rural Health Management and Information Infrastructure, India
15. Mobile-Based Primary Healthcare Management System, India
16. Map of Medicine for Kijabe Hospital, Kenya
17. Nokia Data Gathering, Brazil
18. PDAs for Malaria Monitoring, Mozambique
19. Phones for Health, Rwanda
20. TRACnet, Rwanda
39
Remote Monitoring
21. Cell-Life Project, South Africa
22. Chinese Aged Diabetic Assistant (CADA), China
23. Colecta-PALM, Peru
24. Mashavu: Networked Health Solutions for the Developing World, Tanzania
25. MediNet Healthcare Management System, Trinidad and Tobago
26. Mobile Care, Support and Treatment Manager (MCST), India
27. Mobile Phones for Health Monitoring, India and the United Kingdom
28. Phoned Pill Reminders for TB Treatment, Thailand
29. SIMpill Solution for TB, South Africa
30. Virtual Health Pet, Brazil
31. Enhancing Nurses Access for Care Quality and Knowledge through Technology (ENACQKT), the Caribbean
32. HealthLine, Pakistan
33. Mobile HIV/AIDS Support, Uganda
34. Primary Healthcare Nursing Promotion Program, Guatemala
35. Uganda Health Information Network (UHIN), Uganda
36. Acute Encephalitis Syndrome Surveillance Information System (AESSIMS), India
37. Alerta DISAMAR, Peru
38. FrontlineSMS, Worldwide
39. GATHER, Uganda
40. Handhelds for Health, India
41. Remote Interaction, Consultation, and Epidemiology (RICE), Vietnam
42. Tamil Nadu Health Watch, India
43. Cell Phone Applications for Clinical Diagnostic Therapeutic and Public Health Use by Front Line Healthcare
Workers, Mozambique
44. Digital Inclusion Kit in Health and Higher Education, Argentina
45. Ericsson and Apollo Hospitals Initiative, India
46. HIV Mobile Decision Support, South Africa
47. M-DOK: Mobile Telehealth and Information Resource System for Community Health Workers, Philippines
48. Mobile E-IMCI, Tanzania
49. Mobile Telemedicine System, Indonesia
50. Nacer, Peru
51. Teledoc - Jiva Healthcare Project, India
Credit: DataDyne
40
Credit: RAMP
Project 1: Freedom HIV/AIDS Project
Country: India
Sponsoring Organization and Partners: ZMQ Software Systems and Delhi State AIDS Control
Society
Application Area: Education and Awareness
Communicating information in an engaging, fun way is a critical ingredient of success in mHealth programs.
The Freedom HIV/AIDS games—launched in India in December 2005—have effectively enhanced HIV/AIDS
awareness by applying this principle. The games are tailored to target users from different social and demographic groups and run on more than 100 types of mobile phones, from the most basic to the most sophisticated. ZMQ Software Systems, the maker of the games, believes the “Play-and-Learn method [the games
employ]…makes learning not only exciting and engaging but helps in the enhancement and retention of
knowledge.” This belief has been confirmed by the games’ popularity: by March 2006, only four months after the launch date, more than ten million games had been downloaded, many by mobile phone subscribers
in small cities and towns, the most vulnerable populations.
Reference sources:
http://www.freedomhivaids.in/FreedomHivAids.htm
http://www.zmqsoft.com/
Project 2: Learning About Living
Country: Nigeria
Sponsoring Organization and Partners: The UK charity OneWorld, ActionAid International Nigeria,
Action Health Incorporated, Education as a Vaccine Against AIDS (EVA), Butterfly Works Netherlands,
MTN Foundation and Federal Ministry of Education and Federal Ministry of Health, Nigeria
mHealth programs that take a holistic approach to public health challenges often have the best chance of
success. Learning about Living, a collaborative pilot program, does this by providing young Nigerians with
an anonymous forum to learn about health, AIDS, sex, relationships, personal development, and living skills.
The program includes an interactive eLearning tool based on the Nigerian Family Life and HIV/AIDS Education (FLHE) curriculum, as well as the mobile phone-based programs MyQuestion and MyAnswer. With
MyQuestion, Nigerian youth can submit questions via text message, a telephone hotline, or online. Questions are promptly answered by trained volunteers. MyAnswer sends out a monthly question (e.g., what is
the difference between HIV and AIDS?) and selects winners based on responses submitted via the web or
text message. The two-year project, launched in February 2007, was piloted in three locations in Nigeria,
and saw early success. The service received more than 2,500 questions in the first five days and received
10,000 questions in the first month.
Reference sources:
http://blog.whoiswho.de/stories/31872/
http://mobileactive.org/ask-about-sex-text-teenagers-learn-about-living-nigeria
http://uk.oneworld.net/article/archive/9789
http://www.comminit.com/en/node/269380/38
http://www.learningaboutliving.com/south/about
http://www.youtube.com/watch?v=UCHPH-Nx-hc
41
Project 3: HIV/AIDS Video Distribution by Mobile Phone
Country: Georgia
Sponsoring Organization and Partners: Save the Children and UNICEF
HIV/AIDS receives little attention in regions such as the Caucasus, where the topic is taboo and many people are uninformed about the disease and its causes. Save the Children and UNICEF collaborated in January 2008 to produce a 20-minute film about HIV/AIDS aimed at educating young people in Georgia. The film
content is compelling, featuring well-known young actors who portray the potential health risks of everyday
decisions and behaviors. Taking advantage of the popularity of mobile phones among young Georgians,
Save the Children and UNICEF converted the film into a format that is viewable on mobile phones, at which
point it was sent to thousands of young people around the country, who were encouraged to pass it on to
friends. The project was praised for its novelty and the ease of dissemination. This innovative social distribution model for health information had never been used in Georgia before, but is sure to be replicated in
future initiatives.
Reference source:
http://www.unicef.org/ceecis/media_8237.html
Project 4: HIV Confidant
Sponsoring Organization and Partners: Dimagi, Inc. (privately held software company)
In places where HIV-positive status remains a stigma, successful outreach efforts must address people’s
privacy and confidentiality concerns. The HIV Confidant project aims to encourage HIV/AIDS testing by
ensuring secure distribution of test results through the use of handheld computers and standard encryption techniques. Dimagi, a US-based software company, implemented the HIV Confidant project in 2003 at
the Africa Centre for Health and Population Studies in South Africa. In the pilot, 45,000 adults were tested
for HIV, and results were shared with participants through a secure PDA-based system. People who were
tested were provided with a unique ID code, and results were given only to those who provided the code.
The HIV Confidant system runs on Palm m500 and Handspring Visor PDAs, but can be adapted for nonPalm devices for greater flexibility and extended reach.
Reference sources:
http://www.dimagi.com/content/hiv-confidant.html
http://www.technologyreview.com/computing/13776/?a=f
Credit: UN Tim McKulka
42
Education and Awareness/ Remote Data Collection
Project 5: Project Masiluleke
Sponsoring Organization and Partners: Praekelt Foundation, iTeach, National Geographic, Nokia
Siemens Networks, MTN, Ghetto Ruff, Children of South African Legacies, Aricent and frog design
See case study on page 22.
Reference sources:
http://newsvote.bbc.co.uk/2/hi/technology/7688268.stm
http://www.poptech.org/project_m/
http://opensourcepbx.tmcnet.com/news/2008/10/24/3730564.htm
http://www.frogdesign.com/press-release/poptech-unveils-project-masiluleke.html
Project 6: Text to Change (TTC) – HIV Prevention Through SMS Quiz
Country: Uganda
Sponsoring Organization and Partners: Text to Change (TTC), Zain (previously Celtel), the local
NGO AIDS Information Centre (AIC), the Dutch Ministry of Foreign Affairs and Merck
See case study on page 25.
Reference sources:
http://www.texttochange.com
Interviews with the Text To Change team
Project 7: Cell-PREVEN
Country: Peru
Sponsoring Organization and Partners: Universidad Peruana Cayetano Heredia (Peru), Imperial
College (London), University of Washington (Seattle) and Peru’s Ministry of Health
Application Area: Remote Data Collection
When it comes to effective data collection in remote areas of the developing world, less is often more.
Cell-PREVEN was created to allow access to real-time data to members of the healthcare ecosystem in
Peru. This interactive voice response system enables health workers in the field to collect and transmit data
via basic mobile phones. The data is aggregated in a centralized database and made available to medical
professionals, and the system is designed to send SMS or e-mail alerts if certain symptoms are recorded.
During a three-month pilot test, 797 reports were collected and 374 adverse events were recorded—30
severe enough to trigger an SMS alert to a team leader. The pilot researchers believe that Cell-PREVEN
demonstrates that “cell phones are a feasible means of collecting and reporting data in real-time in remote
communities…it’s not necessary to have the latest Palm Pilot or Tablet PC to create a sophisticated public
health surveillance system.”
Reference sources:
http://www.prevenperu.org/preven/
http://www.prevenperu.org/preven/presentation_curioso.pdf
http://faculty.washington.edu/wcurioso/cellpreven.pdf
43
Project 8: Community Accessible and Sustainable Health System (Ca:sh)
Country: India
Sponsoring Organization and Partners: Media Lab Asia (part of the Ministry of ICT India), Dimagi, Inc.
(privately-held software company) and All India Institute of Medical Sciences
Large, rural areas in developing countries often lack comprehensive collection of health and population data.
In Ballabhgarh, India, Media Lab Asia community health workers used an open source software application on
PDAs called Ca:sh—the Community Accessible and Sustainable Health system—to collect medical and demographic data. The pilot aimed to improve maternal and child health, and used Compaq iPAQs, which could run
a MySQL database capable of storing up to 7,000 records. An evaluation of the five-month pilot “indicated high
acceptance of the technology and reduction in total time for entry of data…the [health workers] were satisfied
with the user interface and were able to depend entirely on the handheld, replacing their existing paper-based
records.” Media Lab Asia now is exploring future applications, such as mobile surveys and disease-case management, and has ported the software to less expensive Palm OS-based devices.
Reference sources:
http://www.dimagi.com/content/cash.html
http://www.medialabasia.in/healthcare.html
http://kaash.sourceforge.net/doc/dyd02.pdf
Project 9: Community Health Information Tracking System (CHITS)
Country: Philippines
Sponsoring Organization and Partners: United Nations Development Program (UNDP) and Asia-Pacific
Development Program (APDP)
Patient education is not the only challenge to improving health in the developing world—often health workers are not equipped with the information they need
to best serve patients. The Community Health Information Tracking System, or CHITS, is an open source
program that helps to ‘train the trainers’ by facilitating
data collection and transmission in rural areas. The
system allows community health workers to send
SMS messages to report injuries and receive training
on health surveillance via their mobile phones. The
CHITS open source community believes they should
teach local health workers “how to use the information system, [and] allow them to gain insight into their
condition…so that they can decide to take action and
be proactive in empowering others to do the same.”
Like many mHealth projects, CHITS had found that
empowering local communities with information and
enabling two-way data flows is an effective strategy.
Reference sources:
http://www.stockholmchallenge.se/datacommunity_
health_informat
http://www.apdip.net/resources/case/rnd48/view
http://www.chits.ph/wiki/
indexphp?title=WhatisCHITS
http://chits.ph/wiki/index.php?title=CHITS_Manifesto
Credit: UN UNHCR
44
Project 10: The Dokoza System
Sponsoring Organization and Partners: Dokoza, State Information Technology Agency (SITA),
Centre for Public Service Innovation (CPSI), Centre for Scientific and Industrial Research (CSIR) and the
Meraka Institute, with the cooperation of South Africa’s National Department of Health
Integrating mobile data collection solutions with existing health information systems is essential to advancing
patient care. The Dokoza system in South Africa seeks to meet this need. It is an SMS-based mobile system
designed to fast-track and improve critical services to HIV/AIDS and TB patients. Dokoza relies on SIM
cards that can be used across networks, which interact with a more complex back-end system that integrates with existing hospital information systems. The integration with existing infrastructure offers the possibility of dramatic improvements to existing patient health information records, and in the 2004 pilot, both
doctors and patients found the system to be user-friendly. Challenges encountered during the pilot include
the duplication of data entry in instances where paper-based systems already existed, and staff shortages
that hampered information collection. Despite the promise of this technology, little new data exists on its
impact since the end of the pilot.
Reference sources:
http://www.changemakers.net/node/1014
http://www.dokoza.co.za/content/patent.asp
http://www.ehealth-connection.org/files/conf-materials/mHealth_%20A%20Developing%20
Country%20Perspective_0.pdf
Project 11: EpiHandy
Country: Uganda, Zambia, Burkina Faso
Sponsoring Organization and Partners: Center for International Health, Norway
Health data collection in the developing world is often hampered by the high costs and inefficiencies of
traditional large-scale paper-based surveys. The EpiHandy tool, a mobile health data collection and record
access program enabled by PDAs, helps to mitigate these issues. EpiHandy has been deployed in many
countries and by many different organizations since its first release in 2003, and has been used in multiyear studies in Uganda, Zambia, and Burkina Faso. In the Uganda study, mobile phones were deployed to
participating clinics and Ministry of Health experts trained the local staff on using the open source JavaRosa
software to fill and submit medical forms. The data from the forms was transmitted across the standard services available on the local mobile network. EpiHandy has yielded positive results during a five-year assessment in which 14 interviewers collected information on breastfeeding habits and child anthropometry in rural
areas of eastern Uganda. Outcomes include greatly reduced data entry errors and broad user acceptance,
as well as cost effectiveness relative to traditional paper-based surveys, increasing the potential for this
already successful solution to scale further.
Reference sources:
http://www.epihandy.com/
http://www.cih.uib.no/
45
Credit: UN Marco Dormino
Project 12: EpiSurveyor
Country: Kenya, Uganda, Zambia (and 20 countries in sub-Saharan Africa by end of 2008)
Sponsoring Organization and Partners: The United Nations Foundation and Vodafone Foundation
Technology Partnership, the World Health Organization and DataDyne
A lack of health data is among the greatest obstacles facing health decision makers. One of the largest and
most heralded mHealth projects, EpiSurveyor, developed by non-profit software provider DataDyne, enables
public health and development professionals to create, share, and deploy health surveys and other forms
on mobile devices. The program runs on free and open software, is easy to use, and can be downloaded
to handheld devices to be used by workers in the field. Successful pilot programs in two countries resulted in more timely and accessible healthcare data, making it easier to strengthen district level healthcare
programs like immunizations and responses to disease outbreaks. An added benefit is that country health
workers become fully self-sufficient in programming, designing, and deploying health surveys, eliminating
the need to contract outside consultants. Building upon the success of the initial programs, in fall 2008 the
partners announced that with the financial backing of the United Nations Foundation and Vodafone Foundation, and the scaling and expertise of the WHO and participating ministries of health, the EpiSurveyor-based
mHealth program would be rolled out in a further 20 countries in sub-Saharan Africa.
Reference sources:
http://www.datadyne.org/?q=episurveyor/home
http://siteresources.worldbank.org/DEVMARKETPLACE/Resources/205097-1099409088482/
Brief-DataDyneEpiSurveyor.pdf
http://www.unfoundation.org/global-issues/technology/mobile-health-for-development.html
Project 13: Integrated Healthcare Information Service Through Mobile
Telephony (IHISM)
Country: Botswana
Sponsoring Organization and Partners: Microsoft Research Digital Inclusion Program and the
University of Botswana
In those developing countries boasting near-saturation of mobile phones, the potential benefits of mHealth
strategies are the greatest. Microsoft and the University of Botswana are taking advantage of mobile telephony’s broad reach in the country to develop an Integrated Healthcare Information Service (IHISM). The
system serves both health workers and the general public. It uses a mobile phone-based software application to allow health workers to capture, store, process, transmit, and access patient records. This results
in lower costs and greater efficiency by eliminating redundancy and reducing the amount of time devoted
to data input. The public can also turn to IHISM for information: individuals pose frequently asked questions
about HIV/AIDS via SMS messages and receive a reply straight to their mobile phones. The project partners
have identified several challenges, including localization and customization for illiterate users, but overall feel
that the system has the potential to become a valuable tool and take on increased scope.
Reference sources:
http://research.microsoft.com/enus/collaboration/papers/botswana.pdf
http://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=04195350
http://research.microsoft.com/enus/um/redmond/about/collaboration/awards/digitalinclusion_awards.aspx.
http://research.microsoft.com/enus/um/redmond/events/fs2006/presentations/40_Nyongesa_071806.ppt
46
Project 14: Media Lab Asia – Shared Resource for Rural Health
Management and Information Infrastructure
Country: India
Sponsoring Organization and Partners: Media Lab Asia (part of the Ministry of ICT, India)
The immense size of India, coupled with the fact that approximately 70% of its one billion citizens live in rural
areas, makes affordable and flexible health data collection techniques a necessity. India’s Media Lab Asia
is working on a project—Shared Resource for Rural Health Management and Information Infrastructure—to
improve health data collection and analysis to better serve the needs of its citizens. The mHealth component of this project is focused on data collection. Health workers will use handheld devices to collect a wide
array of data in the field—medical history, demographics, immunizations, and instances of disease. This data
will be transmitted from the devices to the health information system database, where it can be accessed
on a real-time basis. The solution will be implemented initially in the Mallapuram District of Kerala in India. No
exact dates for project implementation have been published.
Reference source:
http://www.medialabasia.in/healthcare.html
Project 15: Mobile-Based Primary Healthcare Management System
Country: India
Sponsoring Organization and Partners: Center for Development of Advanced Computing (CDAC)
Primary Health Centers are critical in rural India as they provide direct patient care and link patients to the
national health system via referrals. The Center for Development of Advanced Computing (CDAC) is developing a ‘Mobile-Based Primary Healthcare Management System’ to strengthen primary health centers in
both rural areas and urban slums in India. The CDAC was created in 1988 and is a research and development society overseen by India’s Department of Information and Ministry of Communications and Information Technology. A key component of the Mobile-Based Primary Healthcare Management System will be
an SMS-based interface, which will allow patients to transmit information to or receive information from a
central database via a basic mobile phone. Medical staff and health officials will be able to access this database from more sophisticated, web-enabled mobile phones. The project is in the development stage, but is
expected to have a broad geographic scope.
Reference sources:
http://www.w3.org/2008/02/MS4D_WS/papers/cdac-mobile-healthcare-paper.pdf
http://www.cdacbangalore.in
Credit: DataDyne
47
Project 16: Map of Medicine for Kijabe Hospital
Country: Kenya
Sponsoring Organization and Partners: UK National Health Service (NHS), Cisco’s Internet
Business Solutions Group (IBSG)
Doctors in rural areas are often forced to treat individual patients with little or no information about resources in neighboring areas, impeding them from providing optimum care. A joint project was launched in Kenya
in 2006 to address this problem. The project gives Kenyan health workers at Kijabe Hospital access to the
Map of Medicine, a medical information database. The Map of Medicine is a web-based tool that provides
comprehensive, up-to-date information on diagnosis and treatment, presented in easy-to-use flowcharts or
‘care pathways.’ Doctors participating in the pilot study were given PDAs and access to data on HIV/AIDS,
TB, malaria, abdominal pain, diarrhea, and typhoid fever. Results were promising: hospital staff reported that
the data access and entry via the PDAs has led to greater efficiency, more time with patients, and reduced
administrative costs.
Reference sources:
http://www.cisco.com/web/about/ac79/docs/wp/Kijabe_Hospital_CS_1009a.pdf
http://www.medic-to-medic.com/
Project 17: Nokia Data Gathering
Country: Brazil
Sponsoring Organization and Partners: Nokia, Amazonas State Health Ministry
Please see case study write up on page 28.
Reference source:
http://www.nokia.com/nokiadatagathering
Project 18: PDAs for Malaria Monitoring
Country: Mozambique
Sponsoring Organization and Partners: AED-SATELLIFE
Malaria is the prime cause of morbidity and mortality in much of sub-Saharan Africa. Prevention and treatment of the disease are essential to reducing its effects on the population, and the rapid capture of accurate information is a key part of these efforts. The PDAs for Malaria Monitoring project, based in Mozambique, deploys PDAs and GPS devices to increase the ability of health workers implementing malaria
programs to make informed decisions. The workers use the devices to collect data and transmit it via the
GPRS network to a central database. A technical team then maps the geographic data to public health and
resource information. Despite some technical challenges, the results of the project have been positive. Users are able to use the PDAs without difficulty, new data tools and training programs have been created,
and information gathered has helped the Health Ministry to influence and shift the allocation of resources.
Reference sources:
http://www.crdi.ca/iicr/ev-118198-201_102534-1-IDRC_ADM_INFO.html
http://www.idrc.ca/uploads/user-S/12053478761102534_Final_technical_Report--_PDAs_for_Malaria_
Monitoring.pdf
48
Credit: UN Martine Perret
Project 19: Phones for Health
Country: Rwanda
Sponsoring Organization and Partners: The GSMA Development Fund, the U.S. President’s
Emergency Plan for AIDS Relief (PEPFAR), Accenture Development Partnerships, Motorola, MTN and
Voxiva
Most mHealth programs strive to leverage the growth and penetration of mobile phones in developing
countries to strengthen health systems and improve health outcomes. Phones for Health, a large publicprivate partnership, is pursuing this goal using a system developed and deployed by Voxiva at health
ministries in Peru, India, and Rwanda. The program enables health workers in local communities to use a
standard handset equipped with a downloadable application to collect and enter health data. Once the data
is entered and transmitted, it can be integrated into health information systems and accessed by health officials in real time at all levels using the Internet. The system also allows workers to order medicines, send
public health alerts, and download treatment guidelines. The Rwanda pilot follows the successful deployment of a related system—TRACnet—that manages the country’s HIV/AIDS program. Rollouts are planned
for other areas of the health sector in Rwanda and other African countries.
Reference source:
http://gsmworld.com/documents/gsma_case_study_mhealth.pdf
Project 20: TRACnet
Country: Rwanda
Sponsoring Organization and Partners: TRAC (Treatment and Research AIDS Center)—an
institution of the Ministry of Health of Rwanda, Voxiva and the US Center for Disease Control and
Prevention (CDC)
TRACnet is a comprehensive data entry, storage, access, and sharing system created in Rwanda in 2005
by the Treatment and Research AIDS Center (TRAC), part of the Rwandan Ministry of Health. The system is
used to manage critical information on HIV/AIDS patients and monitor anti-retroviral treatment (ART) programs nationwide. Medical personnel can use TRACnet to monitor drug distribution, create and submit reports electronically, and access the most up-to-date information on HIV/AIDS care and treatment. TRACnet
was designed for use with all types of technology and information systems, but today, 90% of the system’s
users access it via mobile phones, rather than more expensive and less reliable computers and Internet
connections. Results of the gradual deployment and development of TRACnet have been promising. By the
end of 2005, 21 medical centers had switched from inefficient paper-based systems to TRACnet’s electronic
records system. By 2007, TRACnet covered all 168 health facilities that provide ART treatment, and there
were plans to extend the system to 400 more health facilities. Rwanda’s Ministry of Health also hopes to
expand the system to cover other chronic illnesses.
Reference sources:
http://www.un.org/esa/sustdev/publications/africa_casestudies/tracnet.pdf
http://www.tracrwanda.org.rw/index1.htm
http://www.voxiva.com/casestudies.php?caseid=22
Excerpts from “Local Case Studies from Africa” prepared by the Department of Economic and Social
Affairs, Division for Sustainable Development, United Nations
49
Remote Monitoring
Remote Monitoring
Project 21: The Cell-Life Project
Sponsoring Organization and Partners: The University of Cape Town, the Cape Peninsula University
of Technology and Cell-Life
Application Area: Remote Monitoring
Providing home-based care for HIV/AIDS is critical in the African context, where the stigma attached to the
disease often discourages patients from visiting health facilities. Cell-Life, a social enterprise based in South
Africa, is developing innovative approaches to home care with their ‘Aftercare’ program. In this program, Aftercare health workers monitor patients whom they visit at home. Workers use data-enabled mobile phones
to record information about the patients’ medical status, medication adherence, and other relevant factors.
The data are then transmitted via SMS to the central Cell-Life database, where care managers use a webbased system to access and monitor incoming patient information. Initial program results were encouraging, but significant challenges remain. Although South Africa’s mobile penetration rate is high, the system is
currently used on only one network using prepaid accounts, and the software is not yet available in any of
South Africa’s national languages other than English. Cell-Life is currently working to address these issues
so the program can be adopted on a national scale.
Reference sources:
http://update.cell-life.org/accolades/Commonwealth%20Health%20Ministers%20Handbook%20-%20
June%202006.pdf
http://www.wired.com/medtech/health/news/2004/11/65585
http://mobileactive.org/files/MobilizingSocialChange_full.pdf
Credit: Mobiles in Malawi/Josh Nesbit
50
Remote Monitoring
Credit: WFP Paulette Jones
Project 22: Chinese Aged Diabetic Assistant (CADA)
Country: China
Sponsoring Organization and Partners: Microsoft Research, researchers from St Louis University,
Old Dominion University, Beijing Medical University and Peking University First Hospital
Economic development and the resultant lifestyle changes are contributing to rapidly rising diabetes rates in
fast-growing nations such as China. To counter this trend, Microsoft Research and a group of researchers
from several universities and Chinese medical centers are developing a smartphone-based self-management and support system for elderly diabetics in China. The project will use smartphones to send elderly
diabetics recommendations and guidelines related to physical activity, glucose and blood pressure monitoring, weight measurement, and diet. Patients will be trained to enter and send data on glucose levels, and
doctors will be able to track patient data and graphically display data for patients. The system designers will
use a user-centered design approach to develop software that reflects the preferences and capabilities of
the targeted population to achieve maximum usability. The project’s software will be available free of charge
and will work on PDAs and smartphones that run the Windows Mobile operating system.
Reference sources:
http://www.cadaproject.com/
http://www.cadaproject.com/data/poster.pdf
http://research.microsoft.com/enus/um/redmond/about/collaboration/awards/cellphone-healthcare_
awards.aspx#ECE
http://www.cadaproject.com/data/Smart_Phones_for_Older_Chinese_with_Diabetes.pdf
Project 23: Colecta-PALM
Country: Peru
Sponsoring Organization and Partners: The University of Washington, the Peruvian University of
Cayetano Heredia and two Peruvian health clinics (Via Libre and Impacta)
Application Area: Education and Awareness, Remote Monitoring
Patient-based mHealth strategies must have patient buy-in to succeed. Colecta-PALM, an open source,
secure web-based application that delivers Spanish-language surveys via audio on PDAs, was designed to
ensure patient buy-in. A pilot test of this technology was conducted with HIV/AIDS patients in Peru. The patients used PDAs to enter and submit information regarding their ART adherence and behaviors that could
potentially lead to additional HIV transmission. Patients’ medicine compliance and behaviors were assessed
and different types of feedback were provided depending on the user’s risk profile. Of the 31 patients
tested, 27 (74%) reported openness to using PDAs for HIV treatment support. The researchers in this study
believe that these results “suggest that PDAs may be a culturally appropriate way to support ART adherence and safer sex for PLWHA [people living with HIV/AIDS]. Use of tools such as PDAs among PLWHA in
some resource-constrained settings may be acceptable and can build on existing use patterns.”
Reference sources:
http://colectapalm.org/
http://faculty.washington.edu/wcurioso/emulator/e/Poster_Colecta_Palm_07.pdf
http://faculty.washington.edu/wcurioso/kurth_amia_2007.pdf
51
Remote Monitoring
Credit: DataDyne
Project 24: Mashavu: Networked Health Solutions for the Developing
World
Country: Tanzania
Sponsoring Organization and Partners: Pennsylvania State University and Ideablob.com
Lack of sustained, regular care for children is often responsible for the spread of preventable diseases in
the developing world. The ‘Mashavu: Networked Health Solutions for the Developing World’ project was
initiated by students at Pennsylvania State University to tackle this challenge through mobile solutions.
Mashavu (which means ‘chubby-cheeked’ in Swahili) is a computer-based system that enables doctors
to connect with children in developing countries via mobile phones. Essential medical data (e.g., height,
weight, blood pressure, and lung capacity) are collected at Mashavu stations in developing communities
and sent by mobile phone to a remote server. Medical professionals can then ‘electronically adopt’ children
by logging on to a web portal to monitor the children’s health, provide feedback or advice to the child’s
caregivers, and collect health statistics. The student team from Pennsylvania State University is working with
the Mount Meru Peak School and Good Hope orphanage in northern Tanzania to pilot test the system.
Reference sources:
http://live.psu.edu/story/29485
http://www.ideablob.com/ideas/1528-Mashavu-Networked-Health-Solu
Project 25: MediNet Healthcare Management System
Country: Trinidad and Tobago
Sponsoring Organization and Partners: Microsoft Research and University of the West Indies
The Caribbean is a region with very poor healthcare facilities, but a comparatively strong cellular phone
infrastructure. Microsoft Research has provided a grant to professors at the University of the West Indies to
create a mobile phone-based healthcare management system, to be deployed first in Trinidad and Tobago,
followed by a broader regional rollout. The long-term goal is to build a network that integrates medical resources and promotes the sharing of medical information and expertise. The healthcare management system, ‘MediNet,’ will target diabetes and cardiovascular disease. The system is designed to relay information
from patient monitoring devices to a central server via a cellular network. At the server, a data reasoning
engine extracts all relevant information and alerts medical officers about severe cases. It also recommends
appropriate responses such as a follow-up visit or phone call. The system can also send suggestions directly to patients via SMS message or pre-recorded voicemail.
Reference source:
http://research.microsoft.com/enus/um/redmond/about/collaboration/awards/cellphone-healthcare_
awards.aspx#EAD
52
Remote Monitoring
Project 26: Mobile Care, Support and Treatment Manager (MCST)
Country: India
Sponsoring Organization and Partners: ZMQ Software Systems
Keeping HIV/AIDS patients informed of their health status is one of the most basic ways of empowering
them. With that in mind, the Mobile Care, Support and Treatment Manager (MCST) is being created by ZMQ
Software Systems as an attempt to use technology to improve the logistical challenges of HIV/AIDS management in developing countries. The solution is conceived as a global model, but ZMQ admits that localization and adaptation to rural, urban, and peri-urban contexts will be a challenge. MCST will enable HIV/AIDS
patients to use their mobile phones to access their lab tests and medical history reports. They can also use
the system for nutritional planning, create alerts to remind them to take their medication, and connect with
a help line. In addition, the solution can be used in ‘Group Management’ mode for organizations that work
with HIV/AIDS patients. ZMQ is currently seeking partners for this project.
Reference sources:
http://www.freedomhivaids.in/mCST.htm
http://www.zmqsoft.com/
Project 27: Mobile Phones for Health Monitoring
Country: India and the United Kingdom
Sponsoring Organization and Partners: The UK – India Education and Research Initiative (UKIERI),
Loughborough University, Indian Institute of Technology, All India Institute of Medical Sciences, Aligarh
Muslim University and London’s Kingston University
Long considered a ‘rich country disease,’ diabetes is spreading rapidly in the developing world as affluence changes traditional dietary habits. In 2005, engineers at Loughborough University developed a mobile phone health monitoring system to monitor diabetes and other diseases. The system allows doctors
to use mobile phone networks to monitor up to four key medical signals (electrocardiogram heart signal,
blood pressure, levels of blood glucose, and oxygen saturation levels) from patients who are on the move.
Engineers from the UK and India are working to ‘miniaturize the system’ so that sensors are small enough
to be carried by patients while procuring the necessary biomedical data. In Britain, the solution will be used
to improve healthcare delivery, while in India it will connect ‘centers of excellence’ to hospitals and clinics in
more remote areas. Over the next three years, clinical trials will occur in both the United Kingdom and India.
Reference sources:
http://www.lboro.ac.uk/service/publicity/newsreleases/2007/09_health_monitor.html
http://www.ukieri.org/docs/ukieri-awards-details-2007.doc
Project 28: Phoned Pill Reminders for TB Treatment
Country: Thailand
Sponsoring Organization and Partners: The Chiang Mai Public Health Department
The province of Chiang Mai in northern Thailand has a high number of patients with TB—a major cause of
death in much of the developing world. A prime reason for high TB mortality rates is the failure of patients
to take their medications on a regular basis. To combat this trend, the Chiang Mai Public Health Department
piloted a program involving 60 TB patients who were provided with mobile phones that could only receive
incoming calls. Patients then received daily reminder calls to take their medication. Dr. Surasing Visrutarana,
Chief Provincial Health Officer, noted that during a three-month pilot in 2007 the drug-taking consistency
rate for the patients was over 90%, a significantly higher rate of successful treatment than that observed in
the province’s standard TB treatment program. The project was not only effective but inexpensive, with a
cost of just 100 baht ($3) per person.
Reference sources:
http://listmanager.bps-lmit.com/read/messages?id=49295
http://nationmultimedia.com/2007/01/28/national/national_30025286.php
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Remote Monitoring
Project 29: SIMpill Solution for TB
Sponsoring Organization and Partners: SIMpill and Tellumat
Reminders to take daily medication are an effective means to ensure drug regime adherence, which is critical for diseases like TB, where 99% of those infected can be cured with proper medication compliance. The
SIMpill solution is designed to help ensure compliance. SIMpill works by equipping a pill bottle with a SIM card
and transmitter. When the pill bottle is opened, an SMS message is sent to a designated healthcare worker.
If the pill bottle is not opened when expected, the patient gets a text message reminder to take the medication. If the patient then fails to comply, the health worker is prompted to call or visit to encourage the taking
of medication. A 2007 pilot in South Africa to test the system’s efficacy yielded impressive results. The pilot
showed that with SIMpill, 90% of patients complied with their medication regime, compared to the typical 22
to 60% compliance rate without the system. The solution is now available worldwide.
Reference sources:
Paton, C. Thinking in the box. Financial Mail. 19 September 2008. Retrieved via Factiva.
http://www.SIMpill.co.uk
http://free.financialmail.co.za/innovations/07/0302/minn.htm
http://www.itweb.co.za/sections/computing/2005/0501241215.asp?S=IT%20in%20Healthcare&A=ITH&O=TE
Project 30: Virtual Health Pet
Country: Brazil
Sponsoring Organization and Partners: VIDATIS and the Atech Foundation
Virtual Health Pet has taken advantage of the popularity of the Japanese Tamagotchi virtual pets to improve
medication compliance and patient health in Brazil. The virtual health pet, a J2ME software application running
on the patient’s mobile phone and linked to an electronic health records system, interacts with the patient
to remind them to take their medications on time and to monitor their overall health. Alerts are sent out to
caregivers or emergency services if the patient does not respond to its pet’s messages in a timely manner.
Because the software is linked to an electronic health records system, the Virtual Health Pet is able to both
collect patient data and to provide the patient with near real-time information from their medical team. The
Virtual Health Pet won a Special Jury Award at Simagine 2006, but it is uncertain whether the application is
currently being deployed in the field.
Reference sources:
http://developers.sun.com/champions/nardon.html
http://www.tridedalo.com.br/fabiane/index.htm
54
Communication and Training for Health Care Workers
Project 31: Enhancing Nurses Access for Care Quality and Knowledge
through Technology (ENACQKT)
Country: The Caribbean
Sponsoring Organization and Partners: The International Development Research Centre (IDRC)
and the University of Saskatchewan
Application Area: Communication and Training for Health Care Workers
In order for health workers to provide effective patient care, access to timely information is essential. In the
Caribbean, nurses often lack basic resources, work remotely, and are isolated, which makes data sharing challenging. Enhancing Nurses Access for Care Quality and Knowledge through Technology (ENACQKT) empowers nurses by providing training and other services via PDAs. A key component of ENACQKT
is building nurses’ capacity through technology instruction, giving them the means to access healthcare
applications through the PDAs provided by the program. This enhances professional development and
improves quality of care for patients. Project principals report several achievements, including time savings
for nurses and greater access to information, particularly in the areas of medication and treatment support.
The project also reports success in imparting a sense of empowerment to the nurses in terms of speaking
to physicians about conditions, treatments, and diagnosis.
Reference source:
Interview with Pammla Petrucka, Associate Professor with the College of Nursing, University of
Saskatchewan
Project 32: HealthLine
Country: Pakistan
Sponsoring Organization and Partners: Microsoft Research, Carnegie Melon University (CMU), Aga
Khan University (Karachi) and Health and Nutrition Development Society (HANDS)—a Pakistani NGO
One of the chief obstacles to mHealth solutions is literacy, or the lack thereof. To ensure that semi-literate
community health workers have access to critical information, Microsoft and others are developing HealthLine,
a speech recognition-based information system. The
solution is based on Microsoft Speech Server2007 beta
software. The menu-driven program can be accessed via
landlines or mobile phones. Callers specify a topic (or disease) and are walked through a set of menus until they
reach the information they are seeking. The information
is then read to them—from a prerecorded message—
in their local language. HealthLine was tested among a
group of low-literate maternal and child health community
health workers in Pakistan in mid-2007. It will continue to
be tested in the field with the results informing new features, functionality, and enhancements. Ideally, the solution will be scaled across Pakistan for maximum impact.
Reference sources:
http://www.cs.cmu.edu/~healthline/flash/detail/
http://research.microsoft.com/enus/um/redmond/
about/collaboration/awards/digitalinclusion_awards.
aspx#Speech_Interfaces_for_Health_InformationAccess
http://research.microsoft.com/enus/collaboration/
papers/carnegie_mellon.pdf
55
Credit: DataDyne
Project 33: Mobile HIV/AIDS Support
Country: Uganda
Sponsoring Organization and Partners: Trinity College Dublin
‘Training the trainers’—providing healthcare workers in the field with accessible and reliable medical information—is essential for improved health delivery in the developing world. Trinity College Dublin (TCD) is collaborating with the medical school at Makerere Hospital in Kampala, Uganda to explore the potential advantages
of using PDAs in HIV/AIDS care and treatment. The project aims to provide high-quality medical information
and advice to healthcare workers in Uganda and throughout sub-Saharan Africa. After an initial needs assessment, the project leaders—a group of academic clinicians from TCD, the Dublin Institute of Technology,
and North American universities—developed a prototype of a training program on the clinical care, research,
and prevention of HIV/AIDS. The program was to be evaluated by a select group of healthcare workers in
the field. Results of the testing and evaluation have not yet been published.
Reference source:
http://www.universitiesireland.ie/pubs/report0306.pdf
Project 34: Primary Healthcare Nursing Promotion Program
Country: Guatemala
Sponsoring Organization and Partners: The National School for Nurses of Coban (Guatemala),
Canadian Agency for International Development and the Centre for Nursing Studies (Newfoundland,
Canada)
Nursing shortages, especially in rural areas, are common in developing countries (and increasingly in developed ones as well). The National School for Nurses of Coban in Guatemala created the Primary Healthcare
Nursing Promotion Program to increase the number of nursing personnel available to work in rural areas.
One component of this program is a virtual nursing course, which is taught via a combination of telephone
and two-way data communications. Of the first virtual nursing course graduates in 2004, a subset became
‘community tele-facilitators.’ These tele-facilitators were each given a mobile (or satellite) phone, which
they used to link their rural communities with health specialists in urban areas. The pilot test was launched
in 2005 in five municipalities in northern Guatemala and covered 150 communities with a total population of
45,000. At this time, there appears to be continued progress on the virtual nursing training component, but
it is not certain whether the tele-facilitator program continued after the initial pilot test.
Reference sources:
http://www.mspas.gob.gt/
http://www.enecav.edu.gt/
56
Project 35: The Uganda Health Information Network (UHIN)
Country: Uganda
Sponsoring Organization and Partners: Uganda Chartered HealthNet (UCH), AED-SATELLIFE,
Makerere University Medical School, Connectivity Africa and the International Development Research
Center (IDRC) of Canada
Uganda has become a laboratory for efforts to improve two-way data flows between health workers and
government officials, and the Uganda Health Information Network (UHIN) is a prime example of these efforts. UHIN uses PDAs to collect data and to provide continuing medical education services to physicians.
The PDAs send and receive messages via infrared beams that send the signals to battery-operated access
points. The program was launched in 2003 and currently 350 PDAs are being used. They are connected
to 20 access points in different districts of Uganda. Positive impacts were recorded early on: “The network
delivered a 25% savings in the first 6 months...health workers using the handheld technology now have better job satisfaction and [it] is contributing to staff retention...” The UHIN is planning an analysis to determine
if the project has had an impact on health outcomes such as healthcare planning, resource allocation, and
delivery.
Reference sources:
http://unpan1.un.org/intradoc/groups/public/documents/UN/UNPAN030003.pdf
http://pda.healthnet.org/
http://mobileactive.org/files/MobilizingSocialChange_full.pdf
Credit: DataDyne
57
Credit: DataDyne
Project 36: The Acute Encephalitis Syndrome Surveillance Information
System (AESSIMS)
Country: India
Sponsoring Organization and Partners: Voxiva, Program for Appropriate Technology in Health
(PATH) and the Government of Andhra Pradesh
Application Area: Disease and Epidemic Outbreak Tracking
Every year, more than two million children die from preventable diseases in the developing world, and millions more are left impaired. One such culprit, Japanese Encephalitis, a devastating mosquito-borne illness,
can be prevented by a vaccination, but it is not always administered due to its high cost and a lack of data
on the disease’s true prevalence and impact. To begin to tackle this problem, the Government of Andhra
Pradesh, where the disease is endemic, pilot tested an Acute Encephalitis Syndrome Surveillance Information Management System (AESSIMS) in one of its districts. Local health workers used mobile phones (or
web-based technologies) to report incidences of the disease to the AESSIMS system. Decision makers
could access and analyze this data in real time via a variety of tools, including GIS-based maps. It was envisioned that if the pilot test were a success, the AESSIMS system could be rolled out across India and into
other Asian countries. There is no evidence yet, however, that this project was either scaled up or extended.
Reference sources:
58
Project 37: Alerta DISAMAR
Country: Peru
Sponsoring Organization and Partners: The US Navy, the Peruvian Navy and Voxiva
When disease outbreaks occur, timely transfer of information is of the essence. Alerta DISAMAR is a disease surveillance system, based on Voxiva technology, deployed by the Peruvian Navy with support from
the US Navy. The system’s strength lies in its ‘multi-platform flexibility,’ which allows users to transmit or
access data through multiple technologies, including mobile phones and the Internet. Alerts of disease outbreaks are also sent via multiple mechanisms (text messages, voice mail, and e-mail). An evaluation of the
project conducted in 2003 found that within the first year of deployment, Alerta DISAMAR “rapidly improved
disease reporting, allowed officials to obtain quality data in real time, and, most importantly, facilitated improved response to disease outbreaks in a remote region.” Since its launch, the system has reported more
than 80,500 health events over a wide range of medical problems, including diphtheria, yellow fever, snake
bites, diarrhea, and acute respiratory infections.
Reference sources:
http://www.thepresidency.gov.za/learning/cell_tech4.pdf
http://www.govhealthit.com/online/news/94946-1.html
http://revision.dev.voxiva.net/news/121603.asp
Project 38: FrontlineSMS
Country: Worldwide
Sponsoring Organization and Partners: kiwanja.net, the MacArthur Foundation and the Open
Society Institute
Application Area: Education and Awareness, Remote Data Collection, and Disease and Epidemic
Outbreak Tracking
One of the largest and most ambitious mHealth programs in the world is FrontlineSMS. FrontlineSMS is a
PC-based software application used for sending and receiving group SMS messages. It allows NGOs to
run awareness-raising campaigns and competitions, and carry out text-based surveys, or to simply keep in
touch with fieldworkers and supporters. FrontlineSMS gives access to ‘bulk’ SMS technology designed specifically with the NGO sector in mind. Although other bulk SMS systems do exist, almost all require reliable
Internet connectivity—not an option in many developing countries. FrontlineSMS does not require an Internet
connection and works with any GSM network. The software communicates via a mobile phone or modem,
which can be attached to a computer with a USB cable. Users are encouraged to share views, experiences,
and ideas in an online forum and to provide feedback for future versions of the product.
FrontlineSMS has been used for many healthcare campaigns worldwide including:
Africa-wide: Reporting and monitoring avian flu outbreaks
Benin: Sending health alerts to young people about HIV/AIDS, TB, and malaria
Botswana: Coordinating a blood donation program
Ecuador: Running surveys among rural healthcare workers and radio listeners
Malawi: Coordinating healthcare workers and collecting data in the field
South Africa: Providing HIV/AIDS information services to teachers
Tanzania: Tracing patients who fail to keep clinic appointments and sending patient reminders
Uganda: Aiding community-based healthcare in rural communities
Reference sources:
http://www.frontlinesms.com/who/
http://mobilesinmalawi.blogspot.com
http://wiki.mobiles.tacticaltech.org/index.php/FrontlineSMS
59
Project 39: GATHER
Country: Uganda
Sponsoring Organization and Partners: Dimagi, Inc. (privately held software company), AEDSATELLIFE and the Rockefeller Foundation
Achieving data and device interoperability is one of the central challenges in improving data collection in
developing countries. GATHER is a consortium that has developed a set of tools that enable data entry
from a broad range of devices, including desktops, laptops, telephones, PDAs, GPS systems, and bar-code
scanners. GATHER’s first field test is currently taking place in Uganda with the collaboration of the Ugandan
Ministry of Health. Weekly disease surveillance data for 20 health clinics is being collected by mobile phone
and sent to a GATHER server located at the Health Ministry’s Department of Epidemiology. The results of the
Ugandan field test will inform future phases of GATHER development. The developers hope the technology will
be ready for broader deployment by late 2009.
Reference sources:
http://www.gatherdata.org/
http://www.dimagi.com/content/gather.html
Project 40: Handhelds for Health
Country: India
Sponsoring Organization and Partners: St. John’s Medical College (Bangalore), Indian Institute of
Management (Bangalore) and Encore Software
Disease outbreaks often start in small clusters. Technology can play a crucial role in quickly detecting and
containing initial outbreaks so that broader spread of communicable disease can be prevented. In India,
Shashank Garg and Dr. Isha Garg have created Handhelds for Health, a social enterprise that is developing an
open source disease surveillance system. With this system, health workers will be able to use mobile devices
to collect, validate, and transmit data to a centralized server. The server will be accessible to resident experts,
who can use the real-time data to rapidly identify disease trends and make informed public health decisions.
Handhelds for Health will also be able to track non-communicable diseases, such as diabetes, that require
continual medical attention and follow-up. The founders further hope to use the solution to collect and transmit the data required for large, community-based, longitudinal studies of diseases and other health issues.
Reference source:
http://handheldsforhealth.org/
Project 41: Remote Interaction, Consultation, and Epidemiology (RICE)
Country: Vietnam
Sponsoring Organization and Partners: Microsoft Corporation, Thayer School of Engineering at
Dartmouth College and the National Hospital of Pediatrics (Hanoi)
Rural locales in China and Southeast Asia have been identified as potential high-risk areas for SARS and avian
influenza transmission. The Remote Interaction, Consultation, and Epidemiology (RICE) telemedicine system
will include a disease tracking component to facilitate the early detection of such communicable diseases.
Through mobile technology, RICE will also enable “remote medical consultation, epidemiological surveillance
and access to medical knowledge in regions of the world without access to computers or the Internet.” Most
of the interactions among the rural clinics, regional hospitals, and national hospitals will be conducted via
smartphones. A pilot test of the RICE solution was conducted in March 2007 in Vietnam. Volunteers from Dartmouth tested the connection between clinics and hospitals in rural areas and the National Hospital of Pediatrics (NHP) in Hanoi. The researchers also investigated the information needs of rural clinics to inform continuing development of the solution.
Reference sources:
http://media.americantelemed.org/conf/2007/concurrent.htm#t3d
http://dartmed.dartmouth.edu/summer07/pdf/vs_hanoi.pdf
60
Project 42: Tamil Nadu Health Watch
Country: India
Sponsoring Organization and Partners: Voxiva
Following the devastating 2004 tsunami, the US-based technology company Voxiva deployed a phone- and
web-based data collection and disease surveillance system in India’s hard-hit Tamil Nadu state. The ‘Health
Watch’ program, launched in May 2005, makes use of existing communications infrastructure (i.e., mobile phones, fixed-line phones, and the Internet) to allow health workers in remote areas to report disease
incidence data to health officials in real time. The program also allows health professionals in distant medical centers to quickly analyze and share information and resources, and to adequately respond to specific
health-related questions. For the Tamil Nadu project, over 300 primary health center doctors were trained
by Voxiva. The interactive training sessions featured simple, easy-to-use bilingual manuals. Training was
coordinated with local authorities so that disease surveillance and outbreak response protocols were promoted and reinforced.
Reference sources:
http://news.asiaone.com/News/the%2BStraits%2BTimes/Story/A1Story20080627-73159.html
Credit: DataDyne
61
Project 43: Cell Phone Applications for Clinical Diagnostic
Therapeutic and Public Health Use by Front Line Healthcare Workers
Country: Mozambique
Sponsoring Organization and Partners: Microsoft Research, Department of Information Systems
and the University of Melbourne
Application Area: Diagnostic and Treatment Support
Despite being one of the world’s poorest countries, Mozambique has extensive cellular network coverage
and a high percentage of health workers who own mobile phones. This project, supported by Microsoft
Research, aims to take advantage of Mozambique’s ‘wired’ reality. The project principals, researchers from
the University of Melbourne, have created a suite of applications that can run on standard mobile phones.
The applications provide Mozambican health workers with diagnostic and analytical tools including reference material in the phone’s memory, a calculator for determining drug dosage, and a program for analyzing inputs from medical sensors (e.g., low-cost pulse oximeter probes or a simple electrocardiogram). The
project runs from March 2008 to March 2009 and will conclude with an evaluation of the impact and efficacy
of the applications suite.
Reference sources:
http://research.microsoft.com/en-us/um/redmond/about/collaboration/awards/cellphonehealthcare_
awards.aspx#E2B
http://www.ni.unimelb.edu.au/Research%20and%20Activities/Projects/cell.html
Credit: DataDyne
62
Project 44: Digital Inclusion Kit in Health and Higher Education
Country: Argentina
Sponsoring Organization and Partners: University of Buenos Aires, Fundapers (an Argentinean
NGO) and the Microsoft Research Digital Inclusion Program
Application Area: Diagnostic Treatment and Support
Patients in marginalized areas in both urban and rural Argentina lack access to specialized medical centers,
which are often the only sites where vital diagnostic tools are available. Researchers at the University of
Buenos Aires are creating a Digital Inclusion Kit in Health and Higher Education (DIKHAE), which will allow smartphones to wirelessly connect to diagnostic tools like electrocardiograms, enabling sophisticated
diagnoses to be conducted remotely. The test results can be stored on the smartphone until it is in range
of a cellular signal, and then uploaded to a patient records system. A pilot conducted in 2006 received high
marks from medical professionals for the system’s usability. Project sponsors also envision that the DIKHAE
will be able to connect to X-ray, MRI, and other tools in the future.
Reference sources:
http://lsc.dc.uba.ar/digital-inclusion
http://research.microsoft.com/enus/us/collaboration/papers/buenosaires.pdf
Project 45: Ericsson and Apollo Hospitals Initiative
Country: India
Sponsoring Organization and Partners: Ericsson and Apollo Telemedicine Networking Foundation
(ATNF)
In summer 2008, Ericsson and Apollo Telemedicine Networking Foundation (ATNF) signed a Memorandum
of Understanding to “implement telemedicine applications over broadband-enabled mobile networks” in
India. The initiative is anticipated to both decrease costs and improve health care outcomes, particularly for
rural populations. The project specifics have not yet been announced, but mHealth will play a central role.
According to the Chairman of Apollo Hospitals Group: “With the availability of wireless technology, mobile
health will be integrated into the healthcare delivery system. The new mantra could well be ‘Healthcare for
anyone, anywhere, anytime.’ ”
Reference source:
http://www.ericsson.com/ericsson/press/releases/20080605-1225191.shtml
Project 46: HIV Mobile Decision Support
Sponsoring Organization and Partners: Dimagi, Inc. (privately held software company), D-Tree
International, the Harvard School of Public Health and the Harvard University Program for AIDS (HUPA)
Dimagi and its partners have been working since 2005 on a software program for handheld mobile devices
that will help field health workers screen HIV/AIDS patients and determine their medical needs. Dimagi is
partnering with the Harvard University Program for AIDS (HUPA) to develop the solution. A three-month pilot
program was implemented in several hospitals in Tygerberg, South Africa. For this pilot, health workers were
able to use any Windows Mobile 5 device, including most PDA’s and Windows Mobile-based smartphones.
The software was designed to be sensitive to local needs, providing support in several local languages and
a general user-friendly experience. Data were entered and stored in an embedded MySQL database, and
then synchronized with a host computer via Internet or USB connection. Though this project focused on
HIV/AIDS screening, the software and devices could be modified to assist with screening for other illnesses,
or with triage and diagnosis.
Reference sources:
http://www.dimagi.com/content/hiv-support.html
http://www.d-tree.org/index.html
63
Credit: ENACKQT
Project 47: M-DOK: Mobile Telehealth and Information Resource
System for Community Health Workers
Country: Philippines
Sponsoring Organization and Partners: UN Development Programme (UNDP) and the Philippine
Council for Health Research and Development (PCHRD)
In the Philippines, like most island states, many remote communities do not have access to medical specialists. Technology may be limited in these areas and although basic mobile communication is common,
data services such as Internet access may not be available. M-Dok was designed to allow rural community
health workers to use simple SMS technology, with a specially designed graphical user interface, to send
diagnosis and treatment information to specialists in urban areas. M-Dok requires a Java-enabled mobile
phone with Adobe Acrobat Reader software. The project was given a one-year grant by the UNDP, and part
of those funds will be used to develop a network of community health workers and referral physicians for
the system.
Reference sources:
http://www.synapsehealth.com/portfolio.htm
http://www.apdip.net/resources/case/rnd54/view
http://www.idrc.ca/en/ev-81925-201-1-DO_TOPIC.html
64
Project 48: Mobile E-IMCI
Country: Tanzania
Sponsoring Organization and Partners: Dimagi, Inc. (privately held software company), D-Tree
International, the Rockefeller Foundation, WHO and the Jerre D. Noe Professorship
Often, health protocols are instituted but implementation falls short due to lack of resources in developing
countries. D-Tree International, Dimagi, and other partners conducted a joint study that used PDAs to improve adherence to the Integrated Management of Childhood Illness (IMCI) protocols in rural Tanzania. The
WHO and UNICEF developed the IMCI as part of their strategy of combating some of the most common
diseases afflicting children in the developing world. While the IMCI has shown positive results in Tanzania, a
lack of adequate supervision, insufficient training, and less-than-rigorous implementation have weakened its
potential impact. The project’s research team attempted to address these problems by creating a program
called e-IMCI, which runs on a PDA and guides health workers through the IMCI process with step-by-step
instructions. The pilot results for e-IMCI were encouraging, suggesting that the technology employed is
user-friendly enough for clinicians to use, and that both patient care and caregiver efficiency can be improved. Larger-scale and long-term studies are needed to bolster this argument, but early indicators are
positive.
Reference sources:
http://www.dimagi.com/content/mobile-e-imci.html
http://www.d-tree.org/index.html
http://www.cs.washington.edu/homes/bderenzi/Papers/chi1104-bderenzi.pdf
http://www.who.int/child_adolescent_health/topics/prevention_care/child/imci/en/index.html
Project 49: Mobile Telemedicine System
Country: Indonesia
Sponsoring Organization and Partners: Institut Teknologi Bandung (ITB), the International
Development Research Centre (IDRC) of Canada, the United Nations Development Programme’s AsiaPacific Development Information Programme (UNDP-APDIP), Sukabumi Health Office, the Local Authority
Development of Sukabumi and the Information and Communication Department of Sukabumi
Providing adequate health services in all locales in Indonesia, like most island states, is extremely challenging. To overcome this challenge, a large number of technical and health-oriented organizations are
collaborating on a prototype mobile telemedicine system. The system will enable remote consultation and
diagnostics and also facilitate the collection of patient data. Depending on the communications infrastructure available at a specific location—radio, mobile, or landline phones, and the Internet—information will be
shared between patients at ‘mobile telemedicine units’ and doctors at ‘medical service centers.’ As a first
step, researchers conducted field surveys in West Java to inventory health and communications infrastructure. The results of these surveys informed the prototype development. Further enhancements to
the system are being made and the team reports that “the project is challenging” as it integrates so many
disciplines and technologies.
Reference sources:
http://www.researchsea.com/html/article.php/aid/1998/cid/3?PHPSESSID=92ae156683bf
http://www.idrc.ca/en/ev-81916-201-1-DO_TOPIC.html
Credit: RAMP
65
Project 50: Nacer
Country: Peru
Sponsoring Organization and Partners: Voxiva, USAID-funded Pathfinder International program,
Ministry of Health of Peru and Peru’s Regional Health Directorate of Ucayali
Application Area: Remote Data Collection, Remote Monitoring, Diagnostic and Treatment Support, and
Maternal and child mortality remains excessively high in most developing countries. Nacer was created to
decrease by half the number of maternal and infant deaths in the Ucayali region in Peru. The Nacer solution
allows remote healthcare workers to share data with other remote workers, medical experts, and hospitals,
using any telephone (mobile, satellite, or fixed-line telephone systems—personal or public) or Internet technology. A centralized database hosts all of this data and allows for real-time access. Through Nacer, the entire health ecosystem can send and receive information in order to monitor patient health, provide referrals
and follow-up care, and track supplies and disease outbreaks. Madhu Krishna of Voxiva claims that, “should
health personnel report symptoms that are indicative of a serious, underlying health condition in a pregnant
woman, regional health workers can review her records and send voicemail messages and other support to
ensure the woman is receiving appropriate care.”
Reference sources:
http://www.i4donline.net/articles/current-article.asp?articleid=350&typ=News
Project 51: TeleDoc – Jiva Healthcare Project
Country: India
Sponsoring Organization and Partners: The Soros Foundation and Jiva Institute
A shortage of doctors spells inadequate treatment for many in the developing world, especially in remote
rural areas. Connecting health workers in rural areas with doctors through mobile technology is a promising solution to this endemic problem. TeleDoc uses Java-enabled mobile phones to connect village-based
healthcare workers with doctors in urban areas for remote diagnosis and treatment. Doctors receive realtime diagnostic information entered by the healthcare workers and prescribe appropriate treatments. TeleDoc field workers prepare any prescribed medicines at regional offices. These medications are delivered
directly to the home of patients in rural areas by a combination of pharmacies and delivery personnel. In
the spring of 2003, TeleDoc was tested in 15 villages in Haryana, India. The program won the World Summit
Award for eHealth at the World Summit on the Information Society in Geneva in 2003, and has aggressive
plans for expansion.
Reference source:
http://www.comminit.com/en/node/116145
■
Credit: DataDyne
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mHealth for Development: The Opportunity of Mobile Technology

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